US Pharm. 2007;32(9):61-65.

An estimated three to six million Americans (2% to 4% of the population) have fibromyalgia; 80% to 90% of cases occur in women.1-3 Fibromyalgia is typically diagnosed between ages 20 and 50.2,3 Patients often see multiple physicians before receiving a diagnosis.3 The symptoms of the disorder are nonspecific and overlap with those of other health conditions, so the process of elimination required for an accurate diagnosis often takes time, effort, and patience. Unfortunately, there are no diagnostic tests available to confirm the disorder. The diagnosis is based solely on the patient's description of symptoms and physical examination. Due to the lack of objective data to confirm the diagnosis, some health care providers dismiss patients' complaints, and some providers even question the existence of the disorder. 3-7 However, patients with fibromyalgia often experience chronic pain, fatigue, disrupted sleep, and other troubling symptoms that lower quality of life.2,3 It is important for health care providers to recognize and appreciate the pain and suffering associated with this syndrome and to show empathy and caring when providing counseling. Also, chronic pain often presents as a barrier to adherence to recommended interventions, such as physical therapy and exercise. Health care providers can use motivational interviewing techniques to increase adherence with nonpharmacologic and pharmacologic therapies to promote self-efficacy.

Overview of Fibromyalgia
Fibromyalgia is characterized by chronic, generalized musculoskeletal pain, which is often associated with a chronic sleep disorder. To qualify as fibromyalgia, the pain must be bilateral and present above and below the waist and along the spine. 5 In 1990, the American College of Rheumatology recognized fibromyalgia as a chronic, noninflammatory syndrome of the muscles (rather than joints) and established criteria for the diagnosis. These criteria include a history of widespread pain lasting for at least three months and the presence of pain in 11 out of 18 tender point sites on the body when palpitated with approximately 4 kg of pressure (i.e., enough pressure to turn a thumbnail white). When this pressure is applied to a tender point site on a patient with fibromyalgia, the patient will flinch, jump, or pull away.4,5

The three hallmark symptoms of fibromyalgia are musculoskeletal pain, fatigue, and sleep disturbances.4 However, many patients will experience other symptoms such as chronic low back pain, irritable bowel syndrome, restless legs syndrome, mood disorders, temporomandibular joint disorder, chronic headache, chronic fatigue syndrome, chronic pelvic pain, and interstitial cystitis. Also, it is not uncommon for patients to develop cognitive dysfunction, which may be referred to as fibro fog.4 During disease flares, cognitive decline may intensify. At these times, patients with fibromyalgia might find it difficult to process new information, find the right word when talking, and follow a conversation.4,5

The pathogenesis of fibromyalgia is poorly understood but thought to be associated with abnormalities in the central nervous system (CNS) sensory processing and the peripheral tissue, which, when combined, results in a lower pain threshold. CNS changes are thought to be associated with a blunted response of the hypothalamic-pituitary-adrenal axis when the patient encounters a stressor. Also, there might be increased CNS concentrations of substance P, excitatory amino acids, and neurotro­ phins. The skin and muscle tissue might also have increased substance P, DNA fragmentation, and problems with muscle perfusion. It is hypothesized that these alterations lead to a heightened response to all sensory stimuli.6

The treatment of fibromyalgia involves medications, exercise/physical therapy, and counseling. Based on current evidence, the most effective pharmacotherapy are CNS medications, such as antidepressants, anticonvulsants, and muscle relaxants, which affect chemicals such as serotonin, norepinephrine, and substance P within the brain and spinal cord. These medications modulate the patient's perception of pain. The agents with the strongest evidence for efficacy in fibromyalgia are amitriptyline and cyclobenzaprine. There is modest evidence supporting the use of other antidepressants such as selective serotonin reuptake inhibitors (fluoxetine, sertraline) and dual-uptake inhibitors (venlafaxine, milnacipran, duloxetine). Tramadol and the second-generation anticonvulsant pregabalin have also shown some efficacy in one randomized controlled trial. The most effective nonpharmacologic interventions are cardiovascular exercise, cognitive behavioral therapy, patient education, and multidisciplinary counseling.5

Communication Challenges
Patients with fibromyalgia may present with confusion, frustration, and even anger concerning their condition. It is not uncommon for patients to be dissatisfied with their medical care. It may take months to years for a correct diagnosis to be identified.3 Patients often see several physicians and are referred to specialists for further evaluation. As each alternative etiology is ruled out, the patient can become more and more anxious as they wonder what is wrong with them.

This is compounded by the fact that some physicians are not familiar with fibromyalgia, and others doubt its existence due to the subjective nature of the diagnosis. It is not uncommon for patients to encounter health care providers who dismiss their symptoms or downplay the impact of the disorder. Some health care providers may imply that that patient has a psychological illness, making the patient feel that "it is all in their heads" or not real.4,7 The patient might feel that their doctor does not believe them.

In a study by Haugli et al., patients with fibromyalgia were interviewed to explore factors that most significantly impact the doctor–patient relationship.7 Patients reported that the most significant milestone in their condition was receiving a diagnosis that did not imply the source of the pain was psychological. Patients reported that the most stressful aspect of their relationship with their health care provider was the suggestion that their problem was mental. Patients stated that each time they were told that objective data did not show a source for the pain, they felt mistrusted. Health care providers should therefore acknowledge and respect the significant impact that fibromyalgia has on quality of life. It is imperative that patients feel that their health care providers believe them; if not, effective communication will be impossible.

Another important issue that patients with fibromyalgia reported as significantly impacting the patient–provider relationship was a lack of shared understanding with the health care provider.7 Patients expressed frustration when they were given medications without explanation, offered generic advice such as "You need to go home and relax," or told "You need to go jogging" despite the fact they could hardly walk.7 This kind of advice can appear patronizing and lacks caring. When communicating with patients with fibromyalgia, it is very important to use patient-centered communication strategies. It is important for the health care provider to acknowledge the patient's symptoms and explore their impact on the patient through a two-way exchange of information.8

Another challenge that patients with fibromyalgia face is that although they may have a diagnosis, this diagnosis does not have the same "credibility" as other health conditions. 9 Patients with fibromyalgia have an "invisible" disease state with intense symptoms that are poorly understood by all. Some patients feel that there is a stigma associated with the condition. In a study conducted by Thorne et al., one patient said when physicians reviewed her chart and saw the fibromyalgia diagnosis, they flagged her as being a difficult-to-manage patient; she felt they had preconceived ideas.9 This impression might not be too far-fetched. It has been reported that some physicians find patients with fibromyalgia to be very challenging, time-consuming, and demanding. Some physicians may become frustrated with their inability to effectively treat this disorder and find it easier to refer the patient to another care provider.10 If tension exists between patient and provider, neither party will be open to problem-solving discussions.

Finally, since fibromyalgia does not increase mortality, even health care providers who recognize and appreciate the psychosocial consequences of the condition may discount the importance of the disease because it is not life-­
threatening. Patients might feel that they have no network of care, support, information, and counseling following the diagnosis. It is important to have an open dialogue so that the treatment expectations of both the provider and patient correspond. 10


Communication Strategies
Because it is common for a patient in the early stages of the diagnosis of fibromyalgia to feel frustrated and angry with health care providers, it is important to really listen to the patient. This means being able to "hear the patient without judgment." Many patients with fibromyalgia feel judged when they hear a response such as, "It's all in your head…. All of the objective tests look fine." As a result, they do not feel understood or cared for. This creates more stress, which, in turn, can exacerbate the condition. The following are examples of inappropriate and appropriate dialogues demonstrating these principles.

Inappropriate Dialogue
Patient: This has been so frustrating. I have been to three doctors and nobody knows what's wrong with me. I ache all over, and I can't sleep. They tell me it's all in my head, because all of their tests really don't show anything. This is ridiculous.
Pharmacist: Well, I'm sure they're doing the best they can.
Patient: If that's their best, I'm in trouble. I'm not imaging this. I am not sleeping, I'm tired, I'm fatigued, and my body hurts.
Pharmacist: Well, if the tests don't show anything, maybe you're just tired like the rest of us.
Patient: I can see I won't be getting any help here. Never mind. (Patient leaves.)

Discussion: This patient is quite frustrated. She also feels somewhat hopeless. She has a painful illness that deprives her of sleep and leaves her feeling fatigued. Yet, the pharmacist seems to be supporting what her doctors are doing rather than acknowledging her frustration and hopelessness. To make matters worse, the pharmacist minimizes the patient's problems by acting like they are no different than those of anyone else's. Why does this happen? The best answer is called the righting reflex, which is is motivated by the desire to fix a problem and make it better. We want to help the patient feel better but we don't know how, so we try to fix his or her problem. In reality, this produces what is called a paradoxical response--that is, the problem becomes worse. The patient feels more stress, frustration, and anger because he or she doesn't feel understood. Let's look at a more appropriate response.

Appropriate Dialogue
Patient: This has been so frustrating. I have been to three doctors and nobody knows what's wrong with me. I ache all over, and I can't sleep. They tell me it's all in my head, because all of their tests really don't show anything. This is ridiculous.
Pharmacist: You sound very frustrated.
Patient: I am. All in my head? I am in pain and can't sleep.
Pharmacist: You are really going through something very difficult for you and can't seem to get any answers.
Patient: Yes. That's right. I know I need to be patient, but this is so hard, especially since I don't know what the problem is.
Pharmacist: Sounds frightening, and you are starting to have some doubts about whether you will get some answers.
Patient: I just want some help.
Pharmacist: I understand. I know that your doctor has given you a prescription to help with the symptoms you are feeling. I will get that filled and be back to talk to you about it. Maybe this can help until you get some answers.

Discussion: This pharmacist demonstrated listening and empathy. As a result, the patient feels understood as indicated by the response "Yes. That's right." When people don't feel understood, they feel hopeless. Through an empathic response, pharmacists can let patients know that they sense how they feel without judgment.

Conclusion
Responding to patients with fibromyalgia can sometimes be difficult. Patients who are in pain and lack sleep can often feel depressed, frustrated, or angry. We often do not respond well to these emotions because we feel anxious or helpless around them. Pharmacists should become more aware of the righting reflex and the fact that it produces the exact opposite of the desired response. It is importan to listen to the patient and show empathy. It takes courage and caring to accurately reflect back understanding, but it can also be rewarding.

REFERENCES
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