Transcript Slide 1

University of Wisconsin School of Medicine and Public Health
Center for Tobacco Research and Intervention
Psychiatric Sequelae
Of Fibromyalgia
Stevens S. Smith, Ph.D.
Associate Professor / Licensed Psychologist
Department of Medicine
University of Wisconsin School of Medicine and Public Health
Center for Tobacco Research and Intervention
GIM Primary Care Conf. Presentation
Dec. 12, 2007
Disclosure Statement
I have received no research or salary
support related to today’s presentation.
Case: The Story of Mr. O
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Referred for treatment of depression in August 2001
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56 year-old insurance executive
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Supportive wife and children
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Multiple health problems at initial evaluation in 2001:
- Type II diabetes
- Hypertension
- Dyslipidemia
- Sleep apnea
- Mild, intermittent asthma
- Chronic pain
- Bilateral hearing loss
- Fibromyalgia
Selected Medical History
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Self-described “sickly child”
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Surgery for coarctation of aorta – age 13 yrs
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Never used tobacco; no AODA problems
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Fibromyalgia first diagnosed in 2000 at Mayo Clinic
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2002 – 2004: worsening of fibromyalgia pain resulting in
multiple ER, primary care, and specialist visits
Selected Psychiatric History
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First diagnosed with depression in 2000 at Mayo Clinic (when
fibromyalgia was diagnosed); no prior hx of psychiatric illness
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prescribed sertraline
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Initiation of treatment with me for depression - August 2001
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Fall 2001 – consult with Madison psychiatrist
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discontinued sertraline;
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prescribed fluoxetine and clonazepam prn
Evaluated at UW Psychiatry in late 2001
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discontinued fluoxetine
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prescribed bupropion; continued clonazepam prn
Selected Psychiatric History
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Additional psychiatric consults from 2002 – 2004 with
changes in medication and psychiatrists
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bupropion  citalopram  sertraline  mirtazapine
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Because of insurance problems, our psychotherapy was
interrupted from July 2002 to October 2004
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November – December 2004: significant worsening of
depression with suicidal ideation (first time ever)
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exacerbation of health problems, esp. fibromyalgia
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high levels of work-related stress
Selected Psychiatric History
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Mr. O agreed to seek further evaluation and treatment at
Mayo Clinic in January 2005 resulting in a two-week
inpatient stay
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Received medical and psychiatric evaluation
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Diagnosed with MDD, Recurrent, Severe, without psychotic
features
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Received cognitive-behavioral therapy
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Enrolled into an ECT study and received four treatments
Selected Psychiatric History
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Mayo discharge plan:
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recommended follow-up care at Sleep Disorder Clinic,
Fibromyalgia Clinic, and the Pain Rehabilitation Center
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recommended that Mr. O get a new psychiatrist
Mayo discharge medications:
- glyburide, rosiglitazone, metformin, valsartan, fluvastatin,
fluticasone, hydrocodone, aspirin, ibuprofen
- discontinuation of mirtazapine, modafinil, clonazepam, and
gabapentin
- duloxetine started
Selected Psychiatric History
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Mr. O returned to Mayo a few months later for a two-week stay at the
Mayo Comprehensive Pain Rehabilitation Center
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Addressed at Mayo:
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fibromyalgia-related pain
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memory problems
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physical deconditioning
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mood and stress management
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nutritional therapy in regard to diabetes and hyperlipidemia
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discontinuation of ibuprofen and Tylenol #3
Retired in mid-2005; on disability
Fibromyalgia- Diagnostic Criteria
American College of Rheumatology (1990)
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Hx of widespread pain; present for at least 3 months
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Pain in 11 of 18 tender point sites
Fibromyalgia Syndrome:
Symptoms Other Than PAIN
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fatigue
sleep disturbances
morning stiffness
headaches
irritable bowel syndrome
painful menstrual periods
numbness or tingling of the extremities
restless legs syndrome
temperature sensitivity
cognitive/memory problems (“fibro fog”)
difficulty concentrating
History of Fibromyalgia
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Early 1800s – called “muscular rheumatism”
Tender points described in 1824
Psychiatrist in 1880 described widespread pain,
fatigue, and emotional disturbance as “neurasthenia”
1904 – syndrome called “fibrositis”
1976 – term “fibromyalgia” coined
First recognized by the AMA in 1987
ACR diagnostic criteria published in 1990
No consensus on causes, treatments, or nosological
status
Pathophysiology of Fibromyalgia
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Probably results from abnormal central pain
processing
Mechanisms may include:
- Central sensitization
- suppression of descending inhibitory pathways
- excessive activity of glial cells
- abnormalities of neurotransmitter release or
regulatory proteins or both
(Source: Abeles et al., 2007; Annals of Internal Medicine, 146:726-734)
Figure 1 Pathogenesis of pain in fibromyalgia syndrome
Staud R and Rodriguez ME (2006) Mechanisms of Disease: pain in fibromyalgia syndrome
Nat Clin Pract Rheumatol 2: 90–98 doi:10.1038/ncprheum0091
Yunus 2007; Seminars in
Arthritis and Rheumatology,
36:339-356
Fibromyalgia – General Epidemiology
London Fibromyalgia Epidemiology Study
(1999; J Rheumatol., 26(7):1570-6)
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Random community sample of 3395 adults residing
in London, Ontario
Overall prevalence of 3.3% (confirmed by
rheumatologist exam)
4.9% of women; 1.6% of men met ACR criteria
Peak prevalence – ages 55-64: 8% of women
2.5% of men
Fibromyalgia – General Epidemiology
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Population-based Cohort Study using Insurance
Claims (2006; J Clin Rheumatol., 12(3):124-8)
62,000 enrollees over the period 1997 through 2002
Approximately 4.2% met ICD-9 fibromyalgia criteria
Females were 1.64 times more likely than males to
have fibromyalgia
Fibromyalgia patients were 2 to 7 times more likely
to have comorbid conditions (e.g., depression,
anxiety, IBS, CFS, lupus, and RA).
Fibromyalgia – Healthcare Costs
N=33,176 patients per group
(Source: Int J Clin Pract. 2007; 61(9): 1498–1508)
Fibromyalgia – Use of Pain-Related Medication
Fibromyalgia
Patients
(N=33,176)
Comparison
Patients
(N=33,176)
Opioids
37.8%
12.4%
Benzodiazepines
20.1%
5.8%
NSAIDs
29.3%
11.0%
Muscle relaxants
22.4%
3.9%
Antidepressants
38.7%
11.9%
Antidepressant +
Opioid
23.9%
3.4%
Pain-Related
Medication
(Source: Int J Clin Pract. 2007; 61(9): 1498–1508)
Fibromyalgia – Psychiatric Comorbidity:
A Family Study
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Patients recruited from rheumatology outpatient clinics
- 78 fibromyalgia probands + 146 of their relatives
- 40 RA probands + 72 of their relatives
All fibromyalgia patients met ACR criteria
Utilized structured psychiatric interviews for DSM-IV
psychiatric diagnoses
(Source: Arnold et al., 2006; J Clin Psychiatry, 67: 1219–1225)
Fibromyalgia – Psychiatric Comorbidity:
A Family Study
Fibromyalgia
Patients
(N=108)
Comparison
Patients
(N=228)
Mood Disorder
73.1%
34.2%
Any Anxiety Disorder
55.6%
17.5%
Any Substance Use
Disorder
24.1%
19.3%
Eating Disorder
11.1%
2.6%
Somatoform Disorders
2.8%
0%
Lifetime DSM-IV
Disorder
(Source: Arnold et al., 2006; J Clin Psychiatry, 67: 1219–1225)
(Source: Arnold et al., 2006; J Clin Psychiatry, 67: 1219–1225)
Fibromyalgia – Psychiatric Comorbidity:
A Family Study (Arnold et al., 2006)
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Evidence for shared risk factors for fibromyalgia and
mood and anxiety disorders
This and other studies do not support the hypothesis
that fibromyalgia results from psychiatric disorders
Fibromyalgia overlaps with both psychiatric disorders
as well as medical conditions such as CFS, IBS, MCS
(Source: Arnold et al., 2006; J Clin Psychiatry, 67: 1219–1225)
Case: The Continuing Story of Mr. O
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Nasal surgery in 2005 helped his sleep apnea
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Continues to have significant pain and depression
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Since 2005, Mr. O has made concerted but inconsistent effort to use the
coping strategies he learned at Mayo & UW:
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Daily exercise
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Deep breathing
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Relaxation
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Pacing self in terms of exertion
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Appropriate use of medications
Case: The Continuing Story of Mr. O
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Follow-up visits to Mayo (ECT study; Pain Clinic)
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Added trazodone for help with sleep
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Added tramadol and tiagabine for help with pain
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Diabetes has worsened; now using Lantus
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Arthritis now an issue
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Hearing loss has worsened
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Most recent follow-up at Mayo indicated a previously undetected heart
attack; follow-up at Mayo scheduled
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Psychotherapy + duloxetine - ongoing
(Source: Sarzi-Puttini et
al., in press; Semin
Arthritis Rheum. )