Advertisement

Diagnosis and Differential Diagnosis of Fibromyalgia

  • Don L. Goldenberg
    Correspondence
    Requests for reprints should be addressed to Don L. Goldenberg, MD, Department of Rheumatology, Newton-Wellesley Hospital, 2000 Washington Street, MOB—Blue Suite 304, Newton, Massachusetts 02462
    Affiliations
    Department of Rheumatology, Newton-Wellesley Hospital, Newton, Massachusetts, USA
    Search for articles by this author

      Abstract

      Fibromyalgia is a chronic functional illness that presents with widespread musculoskeletal pain as well as a constellation of symptoms including fatigue, cognitive dysfunction, sleep difficulties, stiffness, anxiety, and depressed mood. The diagnosis of fibromyalgia, similar to other functional disorders, requires that organic diseases are not causing the symptoms. Systemic and rheumatic diseases can be ruled out by a patient history, physical examination, and laboratory investigations. Because there are no specific laboratory tests for fibromyalgia, the 1990 American College of Rheumatology (ACR) classification criteria have been used in clinical settings; however, they are not ideal for individual patient diagnosis. Clinicians should be aware of limitations inherent in using tender points in the diagnosis of fibromyalgia. The multiple symptoms of fibromyalgia often overlap with those of related disorders and may further complicate the diagnosis. One of the most challenging diagnostic dilemmas that clinicians face is distinguishing fibromyalgia from other central pain disorders (e.g., irritable bowel syndrome, chronic fatigue syndrome, migraine). Screening questions based on published criteria can be used as a first approach in diagnosing functional illnesses. Numerous studies report a higher prevalence of psychiatric disorders in patients with fibromyalgia. Therefore, a careful history and evaluation should be taken for the presence of primary mood disturbances. To date, there is no “gold standard” for diagnosing fibromyalgia. Until a better clinical case definition of fibromyalgia exists, all diagnostic criteria should be interpreted with caution, considered rudimentary, and subject to modification.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Aaron L.A.
        • Burke M.M.
        • Buchwald D.
        Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder.
        Arch Intern Med. 2000; 160: 221-227
        • Arnold L.M.
        • Hudson J.I.
        • Keck P.E.
        • Auchenbach M.B.
        • Javaras K.N.
        • Hess E.V.
        Comorbidity of fibromyalgia and psychiatric disorders.
        J Clin Psychiatry. 2006; 67: 1219-1225
        • Hwang E.
        • Barkhuizen A.
        Update on rheumatologic mimics of fibromyalgia.
        Curr Pain Headache Rep. 2006; 10: 327-332
        • Wolfe F.
        • Smythe H.A.
        • Yunus M.B.
        • et al.
        The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: report of the Multicenter Criteria Committee.
        Arthritis Rheum. 1990; 33: 160-172
        • Yunus M.B.
        Symptoms and signs of fibromyalgia syndrome: an overview.
        in: Wallace D.J. Clauw D.J. Fibromyalgia & Other Central Pain Syndromes. Lippincott Williams & Wilkins, New York2005: 125-132
        • Yunus M.B.
        A comprehensive medical evaluation of patients with fibromyalgia syndrome.
        Rheum Dis Clin North Am. 2002; 28 (v-vi): 201-217
        • Ersoz M.
        Nerve conduction tests in patients with fibromyalgia: comparison with normal controls.
        Rheumatol Int. 2003; 23: 166-170
        • Goldenberg D.L.
        Fibromyalgia syndrome: an emerging but controversial condition.
        JAMA. 1987; 257: 2782-2787
        • Yunus M.B.
        • Masi A.T.
        • Aldag J.C.
        A controlled study of primary fibromyalgia syndrome: clinical features and association with other functional syndromes.
        J Rheumatol Suppl. 1989; 19: 62-71
        • Yunus M.B.
        • Inanici F.
        • Aldag J.C.
        • Mangold R.F.
        Fibromyalgia in men: comparison of clinical features with women.
        J Rheumatol. 2000; 27: 485-490
        • Mease P.
        • Arnold L.M.
        • Bennett R.
        • et al.
        Fibromyalgia syndrome.
        J Rheumatol. 2007; 34: 1415-1425
        • Blehm R.
        Physical therapy and other nonpharmacologic approaches to fibromyalgia management.
        Curr Pain Headache Rep. 2006; 10: 333-338
        • Goldenberg D.L.
        Office management of fibromyalgia.
        Rheum Dis Clin North Am. 2002; 28: 437-446
        • Wolfe F.
        The relation between tender points and fibromyalgia symptom variables: evidence that fibromyalgia is not a discrete disorder in the clinic.
        Ann Rheum Dis. 1997; 56: 268-271
        • Katz R.S.
        • Wolfe F.
        • Michaud K.
        Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria.
        Arthritis Rheum. 2006; 54: 169-176
        • Wolfe F.
        Pain extent and diagnosis: development and validation of the regional pain scale in 12,799 patients with rheumatic disease.
        J Rheumatol. 2003; 30: 369-378
        • American Psychiatric Association Task Force on DSM-IV
        Diagnostic and Statistical Manual of Mental Disorders: DSM-IV.
        American Psychiatric Association, Washington, DC1994
        • Hudson J.I.
        • Pope H.G.
        The concept of affective spectrum disorder: relationship to fibromyalgia and other syndromes of chronic fatigue and chronic muscle pain.
        Baillieres Clin Rheumatol. 1994; 8: 839-856
        • Clauw D.J.
        Fibromyalgia: update on mechanisms and management.
        J Clin Rheumatol. 2007; 13: 102-109
        • Wolfe F.
        What use are fibromyalgia control points?.
        J Rheumatol. 1998; 25: 546-550
        • Tunks E.
        • Crook J.
        • Norman G.
        • Kalaher S.
        Tender points in fibromyalgia.
        Pain. 1988; 34: 11-19
        • Staud R.
        • Rodriguez M.E.
        Mechanisms of disease: pain in fibromyalgia syndrome.
        Nat Clin Pract Rheumatol. 2006; 2: 90-98
        • Fitzcharles M.A.
        • Boulos P.
        Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals.
        Rheumatology (Oxford). 2003; 42: 263-267
        • Burckhardt C.S.
        • Goldenberg D.
        • Crofford L.
        Guideline for the Management of Fibromyalgia Syndrome Pain in Adults and Children.
        (APS Clinical Practice Guideline Series, No. 4) American Pain Society, Glenview, IL2005
        • Leavitt F.
        • Katz R.S.
        Distraction as a key determinant of impaired memory in patients with fibromyalgia.
        J Rheumatol. 2006; 33: 127-132
        • Leavitt F.
        • Katz R.S.
        • Mills M.
        • Heard A.R.
        Cognitive and dissociative manifestations in fibromyalgia.
        J Clin Rheumatol. 2002; 8: 77-84
        • McBeth J.
        • Silman A.J.
        The role of psychiatric disorders in fibromyalgia.
        Curr Rheumatol Rep. 2001; 3: 157-164
        • Hudson J.I.
        • Pope Jr, H.G.
        The relationship between fibromyalgia and major depressive disorder.
        Rheum Dis Clin North Am. 1996; 22: 285-303
        • White K.P.
        • Nielson W.R.
        • Harth M.
        • Ostbye T.
        • Speechley M.
        Chronic widespread musculoskeletal pain with or without fibromyalgia: psychological distress in a representative community adult sample.
        J Rheumatol. 2002; 29: 588-594
        • Fietta P.
        • Manganelli P.
        Fibromyalgia and psychiatric disorders.
        Acta Biomed. 2007; 78: 88-95
        • Thieme K.
        • Turk D.C.
        • Flor H.
        Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables.
        Psychosom Med. 2004; 66: 837-844
        • Aaron L.A.
        • Bradley L.A.
        • Alarcon G.S.
        • et al.
        Psychiatric diagnoses in patients with fibromyalgia are related to health care-seeking behavior rather than to illness.
        Arthritis Rheum. 1996; 39: 436-445
        • Arnold L.M.
        • Lu Y.
        • Crofford L.J.
        • et al.
        A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder.
        Arthritis Rheum. 2004; 50: 2974-2984
        • Abeles A.M.
        • Pillinger M.H.
        • Solitar B.M.
        • Abeles M.
        Narrative review: the pathophysiology of fibromyalgia.
        Ann Intern Med. 2007; 146: 726-734
        • Arnold L.M.
        • Crofford L.J.
        • Martin S.A.
        • et al.
        The effect of anxiety and depression on improvements in pain in a randomized, controlled trial of pregabalin for treatment of fibromyalgia.
        Pain Med. 2007; 8: 633-638
        • Dadabhoy D.
        • Clauw D.J.
        Therapy Insight: Fibromyalgia—a different type of pain needing a different type of treatment.
        Nat Clin Pract Rheumatol. 2006; 2: 364-372
        • Kurland J.E.
        • Coyle W.J.
        • Winkler A.
        • Zable E.
        Prevalence of irritable bowel syndrome and depression in fibromyalgia.
        Dig Dis Sci. 2006; 51: 454-460
        • Fukuda K.
        • Straus S.E.
        • Hickie I.
        • Sharpe M.C.
        • Dobbins J.G.
        • Komaroff A.
        • International Chronic Fatigue Syndrome Study Group
        The chronic fatigue syndrome: a comprehensive approach to its definition and study.
        Ann Intern Med. 1994; 121: 953-959
        • Thompson W.G.
        • Longstreth G.F.
        • Drossman D.A.
        • Heaton K.W.
        • Irvine E.J.
        • Müller-Lissner S.A.
        Functional bowel disorders and functional abdominal pain.
        Gut. 1999; 45: II43-II47
        • Dworkin S.F.
        • LeResche L.
        Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique.
        J Craniomandib Disord. 1992; 6: 301-355
        • Bartha L.
        • Baumzweiger W.
        • Buscher D.S.
        • et al.
        Multiple chemical sensitivity: a 1999 consensus.
        Arch Environ Health. 1999; 54: 147-149
        • Headache Classification Subcommittee of the International Headache Society
        The International Classification of Headache Disorders.
        Cephalalgia. 2004; 24: 1-160
        • Gillenwater J.Y.
        • Wein A.J.
        Summary of the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland, August 28-29, 1987.
        J Urol. 1988; 140: 203-206
        • International Association for the Study of Pain, Subcommittee on Taxonomy
        Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain.
        Pain Suppl. 1986; 3: S1-S226
        • Aaron L.A.
        • Buchwald D.
        Chronic diffuse musculoskeletal pain, fibromyalgia and co-morbid unexplained clinical conditions.
        Best Pract Res Clin Rheumatol. 2003; 17: 563-574
        • Annemans L.
        • Wessely S.
        • Spaepen E.
        • et al.
        Health economic consequences related to the diagnosis of fibromyalgia syndrome.
        Arthritis Rheum. 2008; 58: 895-902
        • Hughes G.
        • Martinez C.
        • Myon E.
        • Taïeb C.
        • Wessely S.
        The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice.
        Arthritis Rheum. 2006; 54: 177-183
        • White K.P.
        • Nielson W.R.
        • Harth M.
        • Ostbye T.
        • Speechley M.
        Does the label ”fibromyalgia” alter health status, function, and health service utilization?.
        Arthritis Rheum. 2002; 47: 260-265
        • Wolfe F.
        • Clauw D.
        • Fitzcharles M.A.
        • et al.
        Clinical diagnostic and severity criteria for fibromyalgia [abstract].
        Arthritis Rheum. 2009; 10: S210