Intended for healthcare professionals

Rapid response to:

Clinical Review


BMJ 2014; 348 doi: (Published 24 February 2014) Cite this as: BMJ 2014;348:g1224

Rapid Response:

Re: Fibromyalgia

The review by Rahman et al on fibromyalgia [1] describes the disorder as if it is a disease entity characterised by, for example, a certain number of tender points. This is misleading, as tender point counts merely reflect levels of distress. [2] Whilst, indeed because, we recognise the difficulties encountered by this patient group, we suggest that the term fibromyalgia be abandoned for the following reasons:

1] Fibromyalgia is a dimensional or “continuum disorder” and not a “disease” [3]

2] FM is strongly associated with other non-musculoskeletal complaints and emotional distress, which are at least as disabling as the somatic symptoms; it is more appropriately described in terms of “polysymptomatic distress”[3]

3] In our clinical experience assigning a person a label of FM has a negative and disempowering effect on the patient and many of their doctors; once a person ascribes a complaint to, for example, “fibrofog” it suggests that it is external and unalterable. This may transform a person with distress into “a patient with fibromyalgia.”

4] Because FM overlaps with numerous other disorders with medically unexplained symptoms such as irritable bowel syndrome and chronic fatigue syndrome [3] it is more appropriate to treat them within the same specialised service in the general hospital. Experience in Europe suggests that such specialised units for patients with these disorders can be established with multidisciplinary teams

Polysymptomatic distress has been recognised as a somatoform disorder, specifically as a somatic symptom disorder or SSD. [4] Of people with fibromyalgia in the general population 40% satisfy criteria for somatic symptom disorder, prompting Wolfe to remark that – “the idea that fibromyalgia is primarily a somatic symptom disorder is well accepted in the pain and psychological literature, but not in the rheumatology, where the dominant idea is central sensitisation”. [3] People with these diverse complaints present to doctors in all branches of medicine, in particular in primary care. A greater awareness of the psychosocial determinants of musculoskeletal complaints would benefit all doctors by helping them to identify these people earlier in their “patient journey” and prevent the medicalisation and potential for iatrogenic harm that accompanies a diagnosis of fibromyalgia. [5]

[1] Rahman A, Underwood M, Carnes D. Fibromyalgia Br Med J 2014;] 24th February]

[2] McBeth J, MacFarlane G, Benjamin S, Morris S, Silman A. The association between tender points, psychological distress, and adverse childhood experiences. Arthitis Rheum 1999; 42:1397-1404.

[3] Wolfe F, Brahler E, Hinz A, Hauser W. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res 2013; 65: 777-785.

[4] Somatic symptom and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. American Psychiatric Association. Washington DC, 2013:309-327.

[5] Kouyanou K, Pither C, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med 1997; 57:597-604.

Competing interests: No competing interests

06 March 2014
Christopher Bass
consultant in liaison psychiatry
Dr Max Henderson, senior lecturer in Epidemiology and Occupational psychiatry, Inststitute of psychiatry, Kings College London
John Radcliffe Hospital
Oxford OX3 9DU