Introduction: Fibromyalgia (FM) is the term used to describe unexplained the chronic widespread musculoskeletal pain commonly seen by Rheumatologists. Pain is often accompanied by other somatic symptoms, sleep disturbance, fatigue, cognitive and psychiatric disturbances. Various functional somatic syndromes are associated with FM, including chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), temporomandibular disorder (TMD), tension and migraine headache, bladder irritability and chronic pelvic pain. Psychiatric disorders are increasingly prevalent in FM, with 25% of patients having concurrent depression. Anxiety and post-traumatic stress disorder are also seen with greater incidence. The case describes a 38yr old Nigerian lady with FM. Her condition was particularly complex and involved multiple healthcare professionals. This case demonstrates a number of the associated features of FM and highlights the challenges in diagnosis and management that Rheumatologists experience in their day to day practice.
Case description: A 38 year old social worker was referred to Rheumatology in 2014 by her GP. She had reported widespread joint pains since being involved in a road traffic accident in 2013, when her stationary car was rear ended. Following the accident she was bedbound for 4 months with diffuse musculoskeletal pain and low mood. Prior to this she reported good health, with mild asthma only. She was a mother of 7 children and working full time as a social worker. Her GP had initiated treatment with fluoxetine for her mood as well as Gabapentin and Fentanyl patches for pain. Physiotherapy and Osteopathy were of little benefit. In 2014 she was involved in a second road traffic which significantly worsened her symptoms. Claims were in progress for both accidents. On review at her first Rheumatology appointment in July 2014, bloods tests were unremarkable and an MRI of the whole spine was normal. Clinical examination found multiple tender points, but no other abnormalities. Ongoing management involved weekly group sessions at a local psychological service involving cognitive behavioural therapy (CBT). Following Rheumatology advice she was switched to Duloxetine, began counselling and attended a local pain management and rehabilitation service that runs without professional Psychology input. She was able to continue working but on a reduced-hours basis. By January 2015, her symptoms were deteriorating with generalised pain, fatigue, disordered sleep pattern and increasing psychiatric disturbance including self-harm and overdoses. She was having group CBT and regularly attending the local Pain Management Programme (PMP). The accident claim process was delayed and she was moving solicitors. By this point she was unable to continue working. Rheumatology recommended an intensive inpatient PMP. She was assessed in April 2015 at Guy’s & St Thomas’ Hospital by the INPUT PMP. They recognised significant mental health issues that would be challenging within a group-based PMP, and made recommendations for a Community Mental Health assessment. At her next appointment, she had a multidisciplinary assessment however it was agreed that she would not benefit from a PMP until she had adequate Psychiatric input locally in the form of CBT for post-traumatic stress disorder. By this point, she was having multiple different treatments privately via her motor insurers, and also by several NHS providers. Private treatments included trigger point injections at the Harley Street Pain Clinic, TENS and weekly physiotherapy, psychotherapy and osteopathy fortnightly. In the NHS, she was having homeopathic mistletoe injections at the local pain service, as well as frequent appointments with her GP and local Rheumatologist. Following advice from INPUT, she was referred by her GP to NHS Psychiatry. She was self-harming and her anti-depressants were increased. In December 2015, her Psychiatrist concluded that little more could be added from mental health services, that her mental ill-health was a consequence of ‘her physical pain problem’, and that the focus should be on physical rehabilitation and therefore she was discharged from NHS Psychiatric services. By January 2016, her mental state had significantly worsened and she attempted suicide. Subsequently she was taken over under a different Psychiatrist’s care. In April 2016, she developed frequent seizures, which after Neurological evaluation were considered to be non-epileptic. It was suggested that local mental health involvement was a priority in addition to pain management. Over the next few months her GP and Rheumatologist referred to Liaison Psychiatric services due to her complex mental state, however this proved challenging. She was eventually seen in July 2016 by a new NHS Psychologist whose impression was that she would not benefit from their service. In September 2016 she was reviewed in the hospital pain clinic. Had been seen privately prior to this and had been having individual sessions of CBT which was beneficial and enabled a reduction in opioid use. Due to the improvement in her psychological well-being, she was referred back to INPUT pain management programme and re-assessed in November 2016. She has now been deemed appropriate for an intensive residential PMP, which she is currently awaiting. Her solicitors have asked for her medical records to be released to them.
Discussion: This case highlights the complex interplay between the different psychological and physical features of FM, and the complications of litigation. There are suggestions of post-traumatic stress disorder (PTSD) and she had self-harm, overdoses and non-epileptic seizures. Mental ill-health was a significant factor. She was suffering depression and anxiety considered to result from PTSD. Her lifestyle changed from that of a well-functioning employed mother to being almost housebound and relying on significant support from relatives as well as a paid carer. There was difficulty in accessing psychiatric services. An impasse developed between mental health services and pain management, with psychiatry feeling that the priority was pain management, and the multidisciplinary PMP considering that she was unfit for their programme without urgent treatment of her psychiatric condition. With such complex conditions, effective collaboration between healthcare professionals and teams is vital. In this case, it was not optimal. She developed non-epileptic seizures which were linked to her poor mental state. Litigation appeared to be a significant complicating factor. The relationship between trauma, motor vehicle accidents and fibromyalgia is contested. In the majority of cases it is not possible to identify a cause for FM. Jones et al published an epidemiological study of the effects of physical trauma on FM, finding no link with trauma in general and a weak link with road traffic accidents that did not meet the standard statistical test of significance. In a 2014 editorial2, Jones wrote the following: “So, do MVA [motor vehicle accidents] cause FM? Well, clearly, MVA are neither necessary nor sufficient. Also, based on the current best estimates of the association between MVA and FM, one must conclude that, on the balance of probabilities, they do not.” The data linking psychosocial distress with fibromyalgia are voluminous 3. This remains a contentious issue in the Courts.
Key learning points: Litigation remains a controversial issue with some feeling that this is a ‘red flag’ and will adversely affect potential for improvement. Abnormal illness behavior exists in some patients following trauma including road traffic accidents, and can be related to the prospect of financial gain through medicolegal cases. As clinicians we need to be objective in our assessment and documentation especially when providing medical reports. When psychological distress plays a significant role in the patient’s symptoms, a formal psychiatric assessment must be made. In a multicentre study, 66% of patients with chronic widespread pain had traumatic life events or PTSD preceding the onset of symptoms. Patients with PTSD in this study were more frequently unemployed or on sick leave, had increased pain, more somatic and psychological symptoms, had greater disability and were more likely to have depressive disorder. 4 Recognising this significant association between PTSD and FM/chronic widespread pain, should we be more focused in our referrals to mental health services? These patients appear to have more complicated symptomatology, are more difficult to treat and have poorer clinical outcomes compared to patients without a history of traumatic events. Rather than have multiple professionals involved, is there one service best suited to treating patients with multiple functional somatic symptoms? Do regional complex fibromyalgia clinics exist and if so is there proven benefit?