Fibromyalgia Wars: Table 1

Review Fibromyalgia WarsFibromyalgia (FM) is easy to recognize.Patients diagnosed with it have medically unexplained symptoms (MUS) 1 that are often severe and generally include widespread pain, fatigue, sleep disturbance, depressive symptoms, cognitive problems, irritable bowel syndrome, multiple somatic symptoms, and a single partially objective sign -tenderness on palpation 2 .Representing perhaps 2% to 4% of the adult population 3 , patients with FM incur substantial direct and indirect medical costs, including high rates of disablement.FM is a bitterly controversial condition.It pits patients, pharmaceutical companies, some specialty physicians, professional organizations, and governmental agenciesgroups with substantial political and economic power who benefit from the acceptance of FM -against the large majority of physicians, sociologists, and medical historians in what we call the "fibromyalgia wars."The wars are fought over a series of questions that concern the legitimacy of the diagnosis.In the balance is access to care and disability awards for patients; careers, publications, funding, and salaries for academic physicians; profits for pharmaceutical companies; political power that influences government, research agencies, and professional organizations; and rewards for the legal system.The consequences of the dispute are societal and are best understood in terms of medicalization 4 and social construction 5,6 . PATIENTS WITH FM AND THE BATTLE FOR SYMPTOM LEGITIMACYA central concern of patients with FM and similar MUS illnesses is disbelief: that their physicians and the medical profession don't believe them 7,8 ; that physicians see their symptoms as ordinary -something that everyone has at one time or another, not serious, psychosomatic -in your head, a mental problem or the result of depression [6][7][8][9][10][11][12] .Sensing disbelief, the commentaries of FM patients and their interactions with the medical system are filled with a sense of delegitimization, betrayal, and anger 7 .There is a lot at stake.Real diseases are compensable and recognized by insurance companies, proof offered to family, friends, and employers that the problem is real and that it is serious 13 .Against physician doubt, patients and support groups have marshaled powerful forces: the American College of Rheumatology (ACR) criteria for FM establishes FM as "a real diagnosis" 14,15 and the World Health Organization (WHO) provides FM ICD codes.Research on pain mechanisms and brain imaging studies demonstrate neurobiologic and imaging abnormalities 16 that can be considered the basis of their problems.Further support comes from the funding of research about FM by the National Institutes of Health (NIH), and the US Food and Drug Administration's (FDA) approval of drugs for the specific treatment of FM; and by mid-2008 a MEDLINE search would result in more than 5000 citations for FM.Support for FM is strong within professional organizations and academic centers that offer courses and symposia to physicians and the public, often with strong support from the pharmaceutical companies.FM support-group lobbying of the US Congress has led to endorsement and funding for FM research at the NIH and the Veterans Administration (VA).Lobbying at the state level resulted in at least 8 US state legislature or gubernatorial proclamations of "Fibromyalgia Awareness Day."Most recently, ubiquitous media advertising shows happy, upper middle class women made well by the new drugs.Not so real: medical skepticism.Physicians, however, are skeptical about FM 2,6,11,17,18 .In a survey of 400 general practitioners in the UK, 64% thought patients with MUS had psychiatric illnesses and 84% thought they had personality problems 10 .Wessely and Hotopf described FM as occupying "that grey area between medicine and psychiatry that is also occupied by chronic fatigue syndrome (CFS), irritable bowel syndrome, and many others" 19 .The British Medical Journal categorized FM as "non-disease ... [part of a] spectrum disorder" 11 .The medical historian Edward Shorter placed FM in the continuum of psychosomatic ill-See Explaining medically unexplained symptoms, page 679 www.jrheum.org

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