Fibromyalgia: INVISIBLE PAIN Depression and body image © Celeste Duque, Clinical Psychologist (celeste.duque @ gmail.

com) SUMMARY The syndrome of fibromyalgia is a disease that only in 1992 was actually diagnos ed and separated from rheumatological diseases. The fibromyalgia syndrome charac terized, among other symptoms, by: persistent pain in muscles and tendons, sever e headaches, morning stiffness, changes in menstrual cycle, intestinal disorders , changes in the short-term memory, difficulty concentrating , loss of sensation in the hand, absence of stage IV sleep (deep sleep). The diagnosis of fibromyal gia is made in response to pain in at least 11 points among 18 specific pressure points (tender points), tests of blood analysis showed no changes. In this dise ase are often associated with severe depression and it is thought that these lat ter would be the cause of the syndrome. However, research has shown that these a re another of the many consequences of fibromyalgia syndrome. In this investigat ion, involving three subjects diagnosed with fibromyalgia for at least three yea rs, it was found that levels of depression were presented (using the Beck Depres sion Inventory) are high, there was still having low self-esteem and self-concep t and submit a negative body image. And what more important that the disease is the representation that individuals have on health and illness that influenced h ow they will react to the adversities of life (depending heavily on the personal ity, education, life experiences, through social and cultural group friends, but also its spiritual dimension) and all the dimensions of influence and are influ enced by it being necessary to analyze a case, to arrive at an understanding of the individual as a whole, only after that can establish the best intervention s trategies and methods of counseling. Definition Fibromyalgia, derives from the Greek algia my fibro, and means "pain in the fibr ous tissues of muscles." Fibromyalgia is a syndrome that causes musculoskeletal pain (previously called fibrositis) was first described in 1843 as a type of rhe umatism "with painful highly localized spots." The patient suffering from this s yndrome have often been labeled neurotic, due to its numerous unexplained sympto ms. No trials CD / cd 1 laboratory for the diagnosis of fibromyalgia syndrome. Fibromyalgia was reclassi fied in 1992 and was incorporated in the WHO (World Health Organization), 10 th revision of International Statistical Classification of Diseases and Related Hea lth Problems (ICD-10) which came into force on January 1, 1993. The new document defines fibromyalgia as a painful disease that predominantly involves the muscl es. The muscular-skeletal pain radiated is the most common cause of its chronici ty. Excludes thus hypothesis it is a disease of the joints, so it was separated from rheumatological diseases, earning himself the status of disease (hitherto o ften considered a fake illness, with fake symptoms). Signs and symptoms of Fibromyalgia more evident Clinically, we can say that patients have, in addition to widespread pain and fi bromyalgia points (tender points), fatigue and sleep does not repair / restorati on and other symptoms such as paresthesia, subjective feeling of swelling ("ring s no longer serve me") , morning stiffness, dizziness, palpitations, Raynaud's p henomenon (hands and feet swollen and cold fingers with white ends), headache, i mpaired short-term memory and concentration difficulties, irritable bowel syndro me and affective disorders (depression and anxiety) . Next is presented in Table 1 for a list of signs and symptoms frequently associated with fibromyalgia. Table 1 Signs and symptoms associated with fibromyalgia (Wolfe, 1990)

Signs / Pain Symptom diffuse Soreness at least 11 of the 18 points fibromyalgia Fatigue Muscle stiffness morning Sleep Disorders Headache paraesthesia Anxiety S yndrome Premenstrual Syndrome Sicca (dry mouth and eyes) Depression Irritable Bo wel previous urinary infections Raynaud's phenomenon (hands and feet are numb, w hite, cold and Patients% 97.6% 90.1% 81.4% 77.0% 74.6% 62.8% 52.8% 47.8% 40.6% 3 5.8% 31.5% 29.6% 26.3% 16.7% CD / cd 2 Note. Other symptoms found in patients with fibromyalgia as: dizziness, impaired memory (short-term memory is heavily compromised) and concentration, chronic it ching and rash (unpublished data), impotence in men, in women cramps during inte rcourse.€Most fibromyalgia patients are female (80-90%) and, although strikes b oth sexes and all age groups, however, more prevalent in women between 35 and 50 years of age. The most common age of onset of fibromyalgia is between 20 and 40 years may, however, appear at around 2 years or from 65. Wolfe (1993) believes that fibromyalgia affects 2-4% of the population of the United States. There is no official statistical data for Portugal, but it seems that the percentage shou ld be identical, as it remains similar in Canada and several European countries. Table 2 presents schematically the general characterization of fibromyalgia. Table 2 General characteristics of fibromyalgia Age of onset Sex hardest hit in the general population prevalence Cause Chronic Soreness in 11 of 18 points fibromyalgia diffuse pain, fatigue, sleep disturbanc e results from laboratory studies disabling disease 20-40 years Common Female Un known Yes Yes Yes No Yes Normal Etiology The etiology of fibromyalgia remains unknown. Initially classified as an inflamm atory disease and cataloged as rheumatology, for a time thought that this is a p sychogenic illness (the symptoms are not confirmed by medical examinations of su pplementary diagnosis), current researchers are unanimous in the view that depre ssion, if and when This is more a consequence rather than the cause of the disea se. Having thus ruled out that it is a psychiatric illness. CD / cd 3 Currently the most accepted theory is part of a dysfunction of the central nervo us system in regulating pain sensitivity, with an increase of noxious stimuli fr om the muscles, ligaments and joints. Thus, in genetically predisposed individua ls, various stress factors: Infections, physical trauma - resulting from car accidents or work, including fr actures of the spine, among others, Psychological trauma - for example, derived from rape; Repetitive Strain; Sleep Disorders; could cause a change in the centers modulators of pain in spinal cord and brain, evidenced by the decrease of serotonin and an increase in substance P. These ch anges would bring an increase of neurotransmitters in pain sensitivity, allodyni a, alteration of sleep and fatigue. Diagnosis of Fibromyalgia The American College of Rheumatology established diagnostic criteria for fibromy algia in 1990 which are: Table 3 Diagnostic Criteria of Fibromyalgia (ACR, 1990) * History of widespread pain present for at least three months (in addition to axial skeletal pain must

be present! Cervical spine, anterior chest, thoracic spine or lumbar) pain in at least 11 the 18 points of pain to digital compression ** The 18 tender points a re: occipital (2): inserts the sub-occipital muscles Cervical lower (2): earlier parts of the inter-transverse spaces C5-C7 Trapezoidal (2): midpoints top edges of the Supra-spinal (2): above the shoulder blades, near the edges averages Sec ond rib (2): laterally and above the second joints costescapular lateral epicond yle (2): 2 cm distal to the epicondyle Gluteal (2): upper quadrants outside of t he buttocks in anterior fold of muscle Greater trochanter (2): Following the pro minence of the trochanter Knees (2): medial fat pads proximal to the line of the knees Note. * Pain is considered widespread when the soreness is present in all places : bilateral pain (on the right and left side of the body) and pain above and bel ow the waist; ** Must be exerted a pressure of 4 kg of digital which the patient must respond with pain. Figure 1 shows the location of 18 points fibromyalgia. CD / cd 4 Figure 1. Location of points fibromyalgia (http://www.futureon.com/ ~ hunter / f ms.htm, 1998) Treatment of fibromyalgia Treatment is by drug treatment and non-medicated. Use of antidepressants (amitri ptyline, cyclobenzaprine, among others)! investigations have shown to be effecti ve in combating pain, fatigue and sleep disturbance, however, significant improv ements occur with clinically relevant only in 30-40% of patients. Its effect app ears to stabilize or even decrease over time. These drugs, at doses as low as th ose recommended in the treatment of fibromyalgia, not intended for the treatment of depression, but actually improving stage IV sleep (stage non-REM). Concomita ntly, individuals who report improvements in terms of sleep also cite decreased pain. Though the tricyclics are effective,€less than 50% of patients take them regularly due to the large number and severity of side effects, such as dry mout h, vertigo, constipation, excessive sleepiness, hallucinations, or even induce d epression. CD / cd 5 Table 4 Chemicals that help in the treatment of fibromyalgia (adapted from Nye, 1997) Chemical Tradozone Alprazolam Carisoprodol cyclobenzaprine Diphenhydramine Amitriptyline Initial dose (mg) 50 10 0.5 350 50 5 Taking x hours before bedtim e 0 1 0.5 - 0.5 to 1 0 1 2 Maximum dose (more usual) 600 300 150 60 April 1400 Table 5 presents the list of factors affecting fibromyalgia. Table 5 Factors affecting the symptoms of fibromyalgia factors that aggravate co ld or wet weather Poor quality sleep disorders Trauma Stress recurrent physical and / or excessive physical exercise psychological factors that improve Sleep Wa rm or dry repairer / restorer Application of heat in the muscles affected exerci se adapted physical balanced diet and moderate Education Symptoms should be explained in detail to the patient. This should be informed t hat there is no cure for this syndrome and it is a disease that fluctuates betwe en good times (of relative calm) and moments of crisis. Parents must be informed also that the patient treatment of this disease requires a real involvement by the physician but also and mainly the patient, just so you can enjoy a better qu

ality of life. Individuals with fibromyalgia should have access to an education of new hygiene joint creation of new cycles of sleep / wake adapted to their new condition and level of limitation / disability (must be emphasized the importan ce of sleep). Patients with fibromyalgia, the individuals are considered owls, h owever, what happens is suffering from sleep disorders that go through sleepless ness and / or deprivation of stage IV sleep (deep sleep). It is therefore import ant to establish a right time to lie down (between 21.00 and 22.00 hours) in ord er to break with the old rhythms pathogens. CD / cd 6 Learning new healthier behaviors free from physical and psychological stress, ie , must be re-educated so that they are prepared to live with its limitations eff ective getting the best possible quality of life. Should be encouraged to relate to others, not to isolate themselves and learn to manage their time so as to in terleave the time they have (which varies from case to case, but that is very of ten 4-5 hours / day ) by distributing among his professional activities (not oft en find themselves forced to change professions) and the activities enjoyable an d / or entertainment (on which should make a practice of regular and moderate ph ysical exercise, eg walking on foot are ideals, such as cycling). This rehabilit ation / acquisition of new habits following the adoption of a diet in which shou ld be avoided (preferably banned) the following substances: refined sugar, alcoh ol, caffeine, foods saturated in fat, high-calorie foods, the food ready to eat (junk food or fast food) of low nutritional value. These individuals benefit fro m a balanced diet moderate in carbohydrates, proteins and fats. Being considered as the healthiest diet that has the following composition (based on the percent age of calories, not grams): 40% carbohydrates, 30% protein, 30% fat. It is also important to drink plenty of water (2.5 liters / day), because it hel ps release toxins from the body. Treatment Consider, then, roughly speaking, how to handle the treatment of fibromyalgia. Table 6 Diagnosis and Treatment of Fibromyalgia patient reassurance Avoidance of aggravating factors (eg cold, narcotics, steroids, caffeine, stress, etc..) Int roduction of changes at work! when the patient can keep the work is necessary to introduce physical changes in the workplace (eg use of ergonomic chair and keyb oard, etc.). and changes of pace, time and workload. Physical Modalities pharmac ological options (eg, heat, massage sprays, anesthetics, acupuncture, etc.). Aer obic exercise Recreational Active role of the patient CD / cd 7 Psychological study in patients diagnosed with fibromyalgia There are many cases of patients diagnosed with fibromyalgia subject of psycholo gical study, an attempt to better understand the syndrome and the implications a nd limitations made to the daily life of the subject. As we have seen, fibromyal gia affects the subject's life at all levels, not outside the human being a high ly complex,€and a real "box" of surprises! Depression is often present, and not infrequently so salient that eventually stifle all other signs / symptoms and i s therefore a cause of "bad" diagnosis. The question is to what extent is that d epression is, in fact, cause or consequence of fibromyalgia? Analyzing three cas es (female), we sought to ascertain the degree of depression present. Fibromyalg ia was diagnosed for at least three years and depression symptoms and were well known to the patient. It was, also infer the integrity of self-esteem and self-c oncept, linking all of these variables to form an idea of how these individuals deal with their body image.

Sample characterization Three female subjects diagnosed with fibromyalgia for more than three years, res idents in the geographic center of the area who were "forced" to abandon its occ upation first and currently carrying out their professional duties from home wit h a deep time restriction of 8 hours to 3 hours of daily work and that on days t hat are not in "crisis" (relatively rare! on average 2-3 days per week). Methodology Methodology was used as the clinical interview (psycho-diagnostic) and it was st ill appeal the application of the Beck Depression Inventory. Each individual sam ple voluntarily participated in three sessions, with the average duration of 1 h our. In the first session was conducted the survey of the history of life, payin g particular attention to those aspects related to the syndrome. In the second s ession and once created the conditions for trust and empathy, we applied the Bec k Depression Inventory, supplemented with the deepening of his own life. In the third session was a survey on the clinical aspects of self-esteem, self-concept and body image. Psychological characterization of patients with fibromyalgia It was concluded that, because of fibromyalgia patients have always been a healt hy appearance (as people say "good guy"), for which they feel very ill, are ofte n ignored, victimized by doctors (and health professionals in general), family a nd friends, leading them to doubt themselves, to feel guilty and to be achieved in self-esteem, in short a depressing, but it was more a sign that something goe s wrong ... sometimes triggered in order to draw attention to itself, as a cry f or help! CD / cd 8 Patients with fibromyalgia are individuals who are self-imposed pace of work int ense and prolonged in time, as a rule, very unselfish and always ready to help t hose in need, so it is not surprising that despite being possibly feel pain and / or extreme tiredness, are unable to say no! Showing up (pre) arranged the extr a effort when it is expressed to them (or implicitly) requested / required. Negl ect their food, getting to take only one meal a day and even this very frugal. T end to compensate for lack of food with coffee intake and "snacking" Candy (a ca ndy, a cake, a packet of sugar ...). Rarely eat a piece of fruit, vegetables are consumed in tiny quantities. They usually love to cook and take great pleasure in seeing others eat ... Sometimes the smell of food to be cooked, are "a drop o f water" to create the feeling of disgust. The noises and smells are amplified e nvironments, succeeding, for example, in times of crisis that the subject does n ot feel well and could even suffer from breaks tension and imbalances, changes i n vision, when in large stores (such as hypermarkets, Shopping, etc.).. During m uch of his life pass on to others the image of being infallible, true, super-hom em/mulher (sleep little, have intense and long hours of work, and not satisfied just by getting involved in many other extra activities, not rarely play more th an one professional activity - accumulate hours and more than one job). However, without warning, one day your life turns into chaos because of their physical a nd psychological lead him to have to slow down, if not to abandon forever its pa ces. Despite all their efforts fibromyalgia patients feel, literally, skin non-r ecognition of their value by the closest people (family members, employers, acqu aintances and friends) and that's the worst that could happen to them because it has immediate consequences, impacting on levels of self-esteem is very low whic h tends to be compensated (because of this weakness / insecurity) with an inordi nate need for recognition of their value, by the other;€they do not like this i s done your self-esteem suffers even more, their self-image becomes profoundly n egative, and their self-concept gets a big hit (eventually declined against the other and be a permanent doubt about the capabilities) which leads to states of

deep depression and sadness that creep and prolonged in time. The degree of depr ession present in fibromyalgia patients varies from case to case, according to t he personality structure, representations that the subject has on health (but al so about the disease) and how they deal with it, ranging from major depression t he simple depressed mood. CD / cd 9 They live surrounded by stress (physical or psychological) and this is deeply ha rmful to them (indeed, as is generally for humans). Have great difficulty managi ng / coping with stress and, often, still have difficulty in dealing with figure s of authority. They feel deeply frustrated, misunderstood or even "castrated." While in counseling have great difficulty in verbalizing their feelings. What is perfectly normal because even learned throughout life, to silence her feel! acc ustomed to receiving from others the fun (they are considered pretenders, hypoch ondriacs, liars, lazy, etc..; her illness is deeply misunderstood), generates ar ound an environment of mistrust, doubt and are often labeled neurotic and unbala nced - which exacerbates all symptoms, which can trigger serious crisis which ex tend through time. Results Individuals monitored showed high levels of depression. The levels of self-estee m and self-concept are low and body image is extremely distorted, negative, conf irming the depression. Discussion of results The subjects who participated in this study live in depression for some years, d erived from the disability imposed by the disease, and precisely why the depress ion that causes another symptom of fibromyalgia. Had a deep feeling of inadequac y / helplessness in dealing with daily routines, which makes them even more depr essed, so it has proved highly beneficial for these subjects in the sample (but also for those who suffer from this syndrome) be offered them a multidisciplinar y medical monitoring (technical area of medicine, psychiatry, neurology, rehabil itation and health in general), dietary and psychological. The counseling should always adopt a perspective of Clinical Psychology and / or Health, with a stron g component of health education, given the need to provide individuals the tools to better cope with the disease and all symptoms resulting from it. For example : teach them how to manage stress, get them to adopt lifestyles more appropriate t o their current physical condition, to identify and prevent / eliminate risky be haviors: implement healthy eating habits; CD / cd 10 eliminate bad habits of consumption, caffeine, alcohol, addiction to drugs or ot her substances, tobacco, adopt more healthy sleep habits: to establish timetable s and to throw up, that are fulfilled; sleep at least 8-9 hours, to adopt the pr actice of moderate physical exercise and adapted: walking, cycling, aerobics. Promoting thereby Health and resulting in a greater well being and quality of li fe which have, in turn, directly reflected in the self-esteem, self-concept and body image. Patients with fibromyalgia usually still qualify for some relief to enjoy the so-called alternative medicine treatments (which should be seen as com plementary, when practiced by skilled professionals, qualified) such as: massage

, acupuncture, music therapy, aromatherapy, etc.. There are no general formulas more effective, it all depends on the patient and his particular case. What is h ighly beneficial for one may be deeply damaging to another. Interested, rather, do not lose hope and keep your common sense. Sometimes just hearing the "voice o f the body" or consciousness in order to avoid exaggeration and to live better . .. In short, the patient with fibromyalgia should (re) learn to live (accepting their illness / disability), better (con) living with a chronic disease (which h as few of the moments of relief and major crises and suffering) but Also, learn to live better with you (accepting it as it comes with all the virtues and defec ts) and others. Learning to say no! And stop (where necessary and if it depends on their welfare and health) to withdraw enjoyment of life and small victories t hat will slowly catching up. Until it is able to achieve a higher state of equil ibrium in which the symptoms will give you some "respite"€allowing him to stren gthen his hope in life, leaving to mourn. Learning to live one day at a time, as a great gift (there are cases that are literally interpreted as a miracle). Nev er forgetting that, however bad your situation / condition there are always peop le who live or survive in the worst conditions ... REFERENCES CONSULTED Amand, R. P. St. (1998). Fibromyalgia (For Patients). URL: http://www.csusm.edu/ public/guests/ nancym/AboutGuai1997.htm Amand, R. P. St., & Craig Marek, C. (199 9) What your Doctor May Not Tell You about Fibromyalgia: The Revolutionary treat ment that me reverse the disease. New York, NY: Warner Books. American College o f Rheumatology (1990). Criteria for the Classification of Fibromyalgia. Report o f the Multicenter Criteria Committee. Arthtitis Reumatolgy, 33, 160-172 CD / cd 11 Angel, K. (2000). Fribromyalgia. URL: http://content.health.msn.com/content/dmk/ dmk_article_55421 Beck, A. (1982). Cognitive Therapy of Depression. Rio de Janei ro: Zahar Editores. Chaitow, L. N. D. (1995). Fibromyalgia: The Muscle Pain Epid emic! Is it ME (Myalgic Encephalomyelitis) by Another Name? (Part 1). URL: http: //healthy.net/library/articles/chaitow/ fibromy/fibro1.htm Devin, J. S., & Copel and, M. E. (1996). Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual. Oakland, CA.: New Habing Publications. Edelberg, D. (2000). Questions a nd Answers about Fibromyalgia. URL: http://www.americanw holehealth.com/library/ fibromyalgia/fibro1.htm Medeiros, N. (1998). Fibromyalgia: A Description http:// ww.csusm.edu/pubic/guests/nancym/FmDescrip.htm Professional vs. Reality. URL: Neumann, L., & Buskila, D. (1997). Quality of life and physical functioning of r elatives of fibromyalgia patients. Seminar Arthritis Rheum 26: 834-399, NIAMS (N ational Institute of Arthritis and Muskulosketal and Skin Diseases) (1998). Ques tions and Answers about Fibromyalgia. URL: http://www.nih.gov/niams/healthinfo/f ibrofs.htm Nye, D. A. (1997). The Physicians Guide to Fibromyalgia Sybdrome. URL : http://prairie.lakes.com/ ~ roseleaf / fibro / md-faq.html Pattee, P. (1998). Fibromyalgia Treatment. Starlanyl, D. (1998). Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual, Chapter 24. URL: http://www.tidalweb.com/fms/d iet.txt whole-ealth Library (2000). Fibromyalgia. Williamson, M. E. (1996). Fibr omyalgia: a comprehensive approach. Wolfe F, Smythe HA, Yunus MB et al. (1990). The American College of Rheumatology 1990 Criteria for the classification of fib romyalgia. Arthritis Rheum 33, 160-172. Wolfe, F. (1993). Fybromyalgia: on diagn osis and certainty. Musculoskel Journal of Pain, 17, 1 (3-4). *** *** ***

© Celeste Duque - 05/04/2008 CD / cd 12