Fibromyalgia symptoms are diffuse body pain, exhaustive fatigue, and brain fog. Fibromyalgia is a complex syndrome with many underlying factors contributing to the symptoms. The diagnosis is made by a careful history, physical exam, and using the Widespread Pain Index(WPI) and the Symptoms Severity Score(SSS). These, along with appropriate lab work, can make the diagnosis easy. Unfortunately, many endure frustrating years before diagnosis and are given piecemeal explanations and treatments without a holistic, comprehensive approach.
The causes of fibromyalgia involve dysfunction with how the brain and central nervous system process stimuli. Those with fibromyalgia will be sensitive to stimuli that may hurt but do not cause any harm. Neurotypical people would not be bothered, but those with fibromyalgia will be bothered by these innocuous stimuli. Going outside on a sunny day may be unbearable without sunglasses. Going to a sporting event or party with loud noises can be overwhelming for those with fibromyalgia. A warm embrace from a spouse or friend can feel like a painful bear hug. Research using functional MRIs has revealed that the brain processes these stimuli as painful, something to be avoided. Genetics and environmental factors play significant roles.
Fibromyalgia overlaps with Chronic Fatigue Syndrome, where many feel they are two halves of the same walnut. Other central pain-processing syndromes that often fall under the umbrella of fibromyalgia are known as regional pain syndromes.
Examples include
Migraines
TMJ
chronic back pain
Irritable Bowel Syndrome
Interstitial Cystitis.
Postural Orthostatic Hypotension Syndrome (POTS)
Abdominal Migraines
Treatments involve a combination of treatments, including medications and lifestyle interventions. Each intervention has the potential for partial improvement, but one intervention alone is rarely enough to allow recovery. Education is also important. Many struggling have coexisting medical conditions that contribute to and make the symptoms worse. These include sleep problems as well as inflammatory conditions like Rheumatoid Arthritis.
Brain fog is more debilitating than pain and fatigue for many struggling with fibromyalgia and chronic fatigue syndrome.
The symptoms of brain fog include:
Memory issues or forgetfulness, especially short term
Impaired ability to concentrate or stay focused
Getting distracted easily
Decreased alertness
Problems thinking clearly or mental slowness
Executive Function struggles
Difficulty holding a conversation
For those of you who have ADHD, these should sound very familiar. These are symptoms of ADHD. This has prompted researchers to assess how common ADHD is in those with fibromyalgia and other central pain-processing syndromes. A study in 2018 published in the Journal of Pain looked at patients who had fibromyalgia and discovered that 45% had ADHD. They also measured the Fibromyalgia Impact Questionnaire(FIQ). They found that those with combined ADHD and fibromyalgia were ten times more likely to have higher levels of self-reported cognitive impairment. This study may have underestimated the prevalence as only the ADHD WHO v 1.1 was used without more in-depth tools like the DIVA 2.0 and a careful clinical history.
Other studies have shown the connection between fibromyalgia and chronic pain disorders. One study showed 73% of those with Chronic Pain in their clinic had ADHD. Other studies have shown higher levels of cognitive impairment overlapping with ADHD in those with fibromyalgia.
What happens when you treat people with fibromyalgia/Chronic Fatigue Syndrome or chronic pain with stimulants who have coexisting ADHD?
A study by Dr Joel Young demonstrated a marked improvement in fibromyalgia and related symptoms with the use of lisdexamfetamine, the generic for Vyvanse. Fibromyalgia symptoms measured by the FIQ were cut in about half, along with marked improvement in ADHD symptoms. Another study showed improvement with methylphenidate and another with Straterra.
One of the questions on the revised FIQ asks from 0-10, how overwhelmed, on average, have you felt over the last week? Most of my patients struggling with untreated ADHD and fibromyalgia typically report high levels, from 8-10. After treatment with stimulants, levels significantly drop, not uncommonly to the 0-2 range, with patients often forgetting how overwhelmed they felt until I review their prior scores. This is likely due to the emotional dysregulation that occurs with ADHD and contributes to higher levels of inappropriate alarm signals of anxiety and pain. Overlapping dysfunction in nerve signaling affecting dopamine and norepinephrine levels is a likely explanation.
So what should we do with the information? More studies can be done, but it is clear that ADHD occurs much more commonly in those with fibromyalgia-type syndromes. Screening for ADHD should be strongly considered in those with fibromyalgia.
When ADHD coexists, treatment should be implemented. Stimulants are a very effective treatment for ADHD and have demonstrated improvements in fibromyalgia symptoms. Treatment of ADHD also affords more effective implementation of healthy lifestyle choices, which include consistent healthy eating patterns and activity levels. Reduction in the negative emotions of feeling overwhelmed has helped so many of my patients recover from fibromyalgia.
Dr. Michael Lenz is a pediatrician, an internal medicine doctor, and a lifestyle medicine physician. He is the author of the book, "Conquering Your Fibromyalgia: Real Answers and Real Solutions for Real Pain."
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