Symposium on Therapeutic Problems
Diagnosis and Management of Fibrositis Syndrome and Psychogenic Rheumatism William P. Beetham, Jr.,
M.D.'~
An understanding of the fibrositis syndrome is essential in order to distinguish the diffuse musculoskeletal aching associated with many systemic diseases from the symptoms of psychogenic rheumatism caused by emotional stress and muscular strain. Patients with diffuse musculoskeletal aching often present difficult problems in management, but effective therapy cannot be undertaken until adequate diagnostic evaluation has been completed.
FIBROSITIS SYNDROME Definitions and Terminology Fibrositis is a poorly defined and controversial term that is commonly used to describe diffuse musculoskeletal aching and stiffness. 2 , 3, 6 It is a form of nonarticular or soft tissue rheumatism, but unlike the broader term, nonarticular rheumatism, it does not include bursitis and tendinitis. 4 The term fibrositis has variable connotations for different physicians. In this article, fibrositis is defined as a clinical syndrome characterized by diffuse aching and stiffness in muscles, fibrous tissue, and periarticular structures, with inactivity that improves after moderate activity or limbering up. A feeling of stiffness is common on arising in the morning. The duration of stiffness varies considerably but is sigmficant if it lasts at least 15 to 30 minutes. If the stiffness is vague or lasts only a few minutes, it is of doubtful diagnostic value. Fatigue is common, especially at the end of the day. The term fibrositis, as used here, is a clinical syndrome and not a pathologic entity, since pathologic studies have failed to reveal consistent abnormalities. When muscles from patients with fibrositis syndrome are biopsied, they are usually either found to be normal or show 'Section of Rheumatology, Lahey Clinic
Medical Clinics of North America - Vo!. 63, No. 2, March 1979
433
434
WILLIAM
P.
BEETHAM, JR.
Table 1. Causes of Secondary Fibrositis Systemic rheumatic and connective tissue diseases Rheumatoid arthritis Systemic lupus erythematosus Polymyositis and dermatomyositis Systemic scleroderma Polyarteritis nodosa Giant cell arteritis Polymyalgia rheumatica Ankylosing spondylitis Reiter's syndrome Sji:igren's syndrome Other inflammatory diseases Sarcoidosis Psoriasis Ulcerative colitis and Crohn's disease Erythema nodosum
Infection Syphilis Tuberculosis Brucellosis Streptococcal infections Subacute bacterial endocarditis Gonorrhea Influenza German measles Viral hepatitis Endocrine Myxedema Hyperparathyroidism Malignant disease Hypertrophic pulmonary osteoarthropathy Acute leukemia Multiple myeloma Metastatic bone disease Drug Reactions Hypersensitivity vasculitis Drug-induced lupus syndromes
mild nonspecific inflammatory changes. Less often, the terms fibrositis or fibromyositis are used to describe a localized area of soft tissue inflammation and, when used this way, can be a pathologic entity. Disorders Associated with Fibrositis Syndrome Fibrositis can be divided into a primary form with no obvious underlying disease and a secondary form associated with underlying disease. The terms primary and secondary can be misleading, since it is likely that most, if not all, primary fibrositis is caused by a secondary or underlying disorder even though the disorder is not always recognized. The fibrositis syndrome is associated with a variety of conditions and should not be used as an all-inclusive term for musculoskeletal symptoms without a careful search for underlying causes. A search for causes of secondary fibrositis includes systemic rheumatic, immunologic, allergic, neoplastic, endocrinologic, infectious, and inflammatory diseases. Rheumatoid arthritis is one of the commonest causes of fibrositis. Table 1 lists a variety of diseases that may cause a secondary fibrositis syndrome. Evaluation of the Fibrositis Syndrome Fibrositis is commonly associated with the early stages of underlying disease that may not be apparent initially but frequently become evident later in the course of the disease. For example, rheumatoid arthritis may begin gradually with diffuse aching and stiffness on arising in the morning, and several months later the characteristic swelling and deformity of peripheral joints may develop. Progressive aching
435
FIBROSITIS AND PSYCHOGENIC RHEUMATISM
and stiffness in an elderly patient with anemia and a high sedimentation rate could be due to a malignant process or polymyalgia rheumatica. Therefore, it is essential that all patients with diffuse fibrositis have follow-up studies at regular intervals to detect progression of underlying disease. True fibrositis can occur without obvious underlying disease and may subside spontaneously, but it can frequently be related to a specific systemic disorder. Disorders commonly associated with fibrositis may be excluded by appropriate laboratory and radiologic studies. A hemoglobin determination, sedimentation rate, latex test, and antinuclear antibody test should be ordered on all patients with diffuse aching and stiffness. If the symptoms of fibrositis persist and remain unexplained, the patient should undergo a general physical examination. Additional laboratory studies, such as a complete blood cell count and screening profile to include a white blood cell count, differential cell count, blood urea nitrogen, serum glutamic oxaloacetic transaminase (SGOT), uric acid, calcium level, urinalysis, and chest roentgenogram are also obtained. Serum protein electrophoresis, thyroxine level, lupus erythematosus cell preparation, and creatine phosphokinase (CPK) determination are often helpful in evaluating fibrositis. According to the definition used here, fibrositis is a clinical syndrome and mayor may not be associated with abnormal results on laboratory tests. For example, if fibrositis is caused by rheumatoid arthritis, the latex test may be positive, or if fibrositis is caused by polymyalgia rheumatica, the sedimentation rate may be very high. On the other hand, in idiopathic fibrositis, results of all of the laboratory tests may be completely normal. Differentiation of Fibrositis and Psychogenic Rheumatism It is especially important to differentiate the aching and stiffness of the fibrositis syndrome, which is often associated with underlying disease, from the aching of the anxious or depressed patient. The terms fibrositis and psychogenic rheumatism have often been confused in the past. Table 2 contrasts the findings in psychogenic rheumatism
Table 2.
Differentiation of Psychogenic Rheumatism from the Fibrositis Syndrome~'
PSYCHOGENIC RHEUMATISM
Vague, generalized complaints; no consistent pattern Nothing helps Wakes up tired not stiff; no gelling Inappropriate attitude (tense, hostile, nervous, defensive) , Symptoms exaggerated On examination patient overreacts with facial grimacing and touch-me-not withdrawal
FIBROSITIS
Specific complaints; consistent pattern Relief with heat, massage, moderate activity, salicylate, and especially steroids Morning stiffness; gelling Appropriate attitude Symptoms appropriate for findings Physical signs correlate with symptoms
*Modified from a presentation by Philip Hench, M.D., of the Mayo Clinic.
436
WILLIAM
P.
BEETHAM, JR.
with those in patients who have true fibrositis. Hench and Boland 5 have pointed out that patients with psychogenic rheumatism are at the mercy of their internal environment and are moody, hostile, anxious, or depressed, whereas patients with fibrositis are at the mercy of their external environment and are influenced by heat, cold, weather, exercise, rest, and medications. Patients with psychogenic rheumatism often have multiple, vague complaints, and, therefore, history taking is often frustrating and requires extra time. Patients with psychogenic complaints may describe "severe pain" but, when questioned as to the type of pain, are vague and actually describe fatigue, weakness, numbness, pressure, fullness, or burning sensations. They are often worried about constipation, rectal itching, mild rashes, tension headaches, eye irritation, or indigestion. The pattern to their symptoms is not consistent. They wake up tired rather than stiff, and nothing seems to give them relief. In contrast, patients with fibrositis have specific complaints with a definite pattern. They feel stiff on arising in the morning and often improve with moderate activity; the stiffness of fibrositis, however, need not be present only on arising in the morning. Gelling may occur; this is a form of aching and stiffness that occurs after inactivity or rest during the day with limbering up afterward. Unlike psychogenic rheumatism, which nothing seems to help, patients with fibrositis are likely to obtain relief with heat, massage, and salicylates. Steriods usually give marked relief in true fibrositis, and even small doses of steroid can produce dramatic improvement of the aching and stiffness associated with polymyalgia rheumatica. Therefore, one should be reluctant to make a diagnosis of fibrositis if steroids fail to give any relief. Patients with psychogenic complaints often have an inappropriate attitude and appear tense, hostile, nervous, defensive, or depressed. On the other hand, the attitude of patients with fibrositis is usually appropriate for the situation or objective findings. Patients with psychogenic complaints often exaggerate. They do not have ordinary pain but terrible or excruciating pain. They may act as though they are in great distress, but these episodes are often of short duration and are not associated with serious complications. Such patients often give the physician the impression that more should be done to relieve their symptoms.
PSYCHOGENIC RHEUMATISM A diagnosis of psychogenic rheumatism depends on the absence of organic disease, the functional nature of complaints, and the presence of anxiety, depression, or neurosis.! The patient with psychogenic rheumatism often fears or resists the physical examination. The patient may have an exaggerated "touch-me-not" reaction that is out of proportion to objective findings. During the physical examination, the neurotic patient tends to overreact by dramatically withdrawing, facial grimacing, groaning, jumping, or crying out. Often the findings on the
FIBROSITIS AND PSYCHOGENIC RHEUMATISM
437
physical examination are inconsistent. For example, percussion, with the examiner's fist over a painful area, may cause considerable withdrawal and facial grimacing if preceded by the question "Does this hurt? ," which implies that it might cause pain. On the other hand, percussion over the same area later may cause no distress at all if the patient is distracted by conversation during examination. Astasia-Abasia and Camptocormia Two forms of hysterical reaction that illustrate specific examples of psychogenic muscular disorders are astasia-abasia ("unable to stand" and "unable to walk") and camptocormia. When patients with astasia-abasia stand up and take a few normal steps, they lurch wildly or stagger in a bizarre manner often crumpling to the floor if unassisted. These patients may actually demonstrate a remarkable ability to make rapid postural adjustments to prevent falling at the wrong time, and this gait may be quite dramatic. The second form of hysterical reaction is camptocormia, which means bent body. This type of hysterical bent back has been seen in soldiers exposed to combat. These patients are often young men who can bend forward but are unable to straighten their backs while standing, though they are able to do so while lying in bed. This condition can be evaluated further by asking the patient to lie down on a tilt table with the back straight. The table is tilted upright, and the patient is requested to walk forward. The patient suddenly finds himself standing upright, much to his own amazement. Both astasia-abasia and camptocormia are genuine psychogenic hysterical reactions to be distinguished from malingering in which the patient deliberately fakes a symptom for a specific purpose.
COMMON PITFALLS IN THE DIAGNOSIS OF FIBROSITIS When obtaining a history for a possible fibrositis syndrome, the physician should try to avoid asking biased questions. It is best if patients volunteer how they feel on arising in the morning. The examiner should start by asking a general question, such as "How do you feel when you first get up in the morning?" or "At what time of day do you feel the worst?" However, when dealing with patients who give vague answers it may be necessary to resort to direct questions such as "Do you feel stiff on arising in the morning?" In this case, the physician must use more caution in evaluating the answer. In some situations, the examiner may be unable to obtain a history of fibroSitis. For example, some patients are poor historians because of senility or language barrier, and therefore it may not be possible to tell if fibrositis is present. In a true fibrositis syndrome that is masked by anxiety or depression, it is not certain how much is anxiety and how much is fibrositis. This is especially true in young women with systemic lupus erythematosus, and, therefore, it is important to obtain appropriate blood tests
438
WILLIAM
P.
BEETHAM, JR.
for lupus in these patients. Patients with severe fibrositis may have apparent muscle weakness secondary to muscle aching and spasm. These patients may be difficult to differentiate from patients with true muscle weakness secondary to muscle disease, such as polymyositis. They require further muscle studies, such as SGOT and CPK enzyme determinations as well as muscle biopsies and electromyographic studies. Myxedema can also cause diffuse aching and stiffness and should be ruled out by appropriate blood tests. Occasionally, the physician will encounter very stoic patients who are so used to discomfort that they will not admit to significant aching or stiffness. Often a good historian will give a very specific description of fibrositis that can be related upon, and this patient should be studied carefully.
THERAPY AND MANAGEMENT The prognosis of fibrositis will depend on the cause. Patients with this syndrome should have follow-up studies at regular intervals while symptomatic, and if an underlying systemic disease appears, appropriate therapy should be started. Patients with mild :fibrositis without obvious underlying disease often improve with reassurance, two aspirin tablets every four hours, and soaks in a hot tub for relief of muscle aching. If aspirin fails to give relief, a trial of nonsteroidal antiinflammatory drugs, such as indomethacin (Indocin), ibuprofen (Motrin), fenoprofen (Nalfon), naproxen (Naprosyn), tolmetin (Tolectin), or sulindac (Clinoril), can be used. Activities are encouraged as tolerated, but rest periods during the day are often helpful. If the fibrositis is caused by polymyalgia rheumatica, polyarteritis nodosa, dermatomyositis, or systemic lupus erythematosus poorly controlled, use of oral steroids would be justified. However, oral steroids, immunosuppressive drugs, penicillamine, and gold should be avoided in patients with fibrositis syndromes unless a specific disease justifying their use can be identified. Patients with mild psychogenic rheumatism do not need antiinflammatory drugs and often improve with reassurance and emotional support. The muscle tension of anxiety may respond to diazepam (Valium), 5 mg, three or four times a day. Mild depression may improve on antidepressants, such as 50 mg of amitriptyline (Elavil), given as a single evening dose before retiring. However, severe emotional distress may require psychiatric evaluation.
SUMMARY Diffuse aching and stiffness may be caused by a fibrositis syndrome or by psychogenic rheumatism. If fibrositis is present, a careful search for underlying disease is made, and appropriate therapy started depending upon the results of all diagnostic studies.
FIBROSITIS AND PSYCHOGENIC RHEUMATISM
439
REFERENCES 1. Bayles, TB: Psychogenic factors in rheumatic diseases. In Hollander, JL, McCarty, DJ,
2. 3. 4. 5. 6.
Jr (eds): Arthritis and Allied Conditions. Philadelphia, Lea and Febiger, 8th ed, 1972, pp 22~238. Beetham, WP, Jr: Fibrositis syndrome. In Conn, HF (ed): Current Therapy. Philadelphia. W B Saunders Co, 1973, pp 744-745. Beetham, WP, Jr: The fibrositis syndrome vs psychogenic rheumatism. Audio-Digest 24 (#2): Jan 19, 1977, Audio-Digest Foundation, Glendale, CA 91205. Hench, PK: Nonarticular rheumatism. In Katz, WA (ed): Rheumatic Diseases: Diagnosis and Management. Philadelphia, J B Lippincott Co, 1977, pp 608-628. Hench, PS, Boland, EW: The management of chronic arthritis and other rheumatic diseases among soldiers of the United States Army. Ann Intern Med 24:808-825 (May) 1946. Smythe, HA: Non-articular rheumatism and the fibrositis syndrome. In Hollander, JL, McCarty, DJ, Jr (eds): Arthritis and Allied Conditions. Philadelphia, Lea and Febiger, 8th ed, 1972, pp 874-884.
605 Commonwealth Avenue Boston Massachusetts 02215
Diagnosis and Management of Fibrositis Syndrome and Psychogenic Rheumatism William P. Beetham, Jr.,
M.D.'~
An understanding of the fibrositis syndrome is essential in order to distinguish the diffuse musculoskeletal aching associated with many systemic diseases from the symptoms of psychogenic rheumatism caused by emotional stress and muscular strain. Patients with diffuse musculoskeletal aching often present difficult problems in management, but effective therapy cannot be undertaken until adequate diagnostic evaluation has been completed.
FIBROSITIS SYNDROME Definitions and Terminology Fibrositis is a poorly defined and controversial term that is commonly used to describe diffuse musculoskeletal aching and stiffness. 2 , 3, 6 It is a form of nonarticular or soft tissue rheumatism, but unlike the broader term, nonarticular rheumatism, it does not include bursitis and tendinitis. 4 The term fibrositis has variable connotations for different physicians. In this article, fibrositis is defined as a clinical syndrome characterized by diffuse aching and stiffness in muscles, fibrous tissue, and periarticular structures, with inactivity that improves after moderate activity or limbering up. A feeling of stiffness is common on arising in the morning. The duration of stiffness varies considerably but is sigmficant if it lasts at least 15 to 30 minutes. If the stiffness is vague or lasts only a few minutes, it is of doubtful diagnostic value. Fatigue is common, especially at the end of the day. The term fibrositis, as used here, is a clinical syndrome and not a pathologic entity, since pathologic studies have failed to reveal consistent abnormalities. When muscles from patients with fibrositis syndrome are biopsied, they are usually either found to be normal or show 'Section of Rheumatology, Lahey Clinic
Medical Clinics of North America - Vo!. 63, No. 2, March 1979
433
434
WILLIAM
P.
BEETHAM, JR.
Table 1. Causes of Secondary Fibrositis Systemic rheumatic and connective tissue diseases Rheumatoid arthritis Systemic lupus erythematosus Polymyositis and dermatomyositis Systemic scleroderma Polyarteritis nodosa Giant cell arteritis Polymyalgia rheumatica Ankylosing spondylitis Reiter's syndrome Sji:igren's syndrome Other inflammatory diseases Sarcoidosis Psoriasis Ulcerative colitis and Crohn's disease Erythema nodosum
Infection Syphilis Tuberculosis Brucellosis Streptococcal infections Subacute bacterial endocarditis Gonorrhea Influenza German measles Viral hepatitis Endocrine Myxedema Hyperparathyroidism Malignant disease Hypertrophic pulmonary osteoarthropathy Acute leukemia Multiple myeloma Metastatic bone disease Drug Reactions Hypersensitivity vasculitis Drug-induced lupus syndromes
mild nonspecific inflammatory changes. Less often, the terms fibrositis or fibromyositis are used to describe a localized area of soft tissue inflammation and, when used this way, can be a pathologic entity. Disorders Associated with Fibrositis Syndrome Fibrositis can be divided into a primary form with no obvious underlying disease and a secondary form associated with underlying disease. The terms primary and secondary can be misleading, since it is likely that most, if not all, primary fibrositis is caused by a secondary or underlying disorder even though the disorder is not always recognized. The fibrositis syndrome is associated with a variety of conditions and should not be used as an all-inclusive term for musculoskeletal symptoms without a careful search for underlying causes. A search for causes of secondary fibrositis includes systemic rheumatic, immunologic, allergic, neoplastic, endocrinologic, infectious, and inflammatory diseases. Rheumatoid arthritis is one of the commonest causes of fibrositis. Table 1 lists a variety of diseases that may cause a secondary fibrositis syndrome. Evaluation of the Fibrositis Syndrome Fibrositis is commonly associated with the early stages of underlying disease that may not be apparent initially but frequently become evident later in the course of the disease. For example, rheumatoid arthritis may begin gradually with diffuse aching and stiffness on arising in the morning, and several months later the characteristic swelling and deformity of peripheral joints may develop. Progressive aching
435
FIBROSITIS AND PSYCHOGENIC RHEUMATISM
and stiffness in an elderly patient with anemia and a high sedimentation rate could be due to a malignant process or polymyalgia rheumatica. Therefore, it is essential that all patients with diffuse fibrositis have follow-up studies at regular intervals to detect progression of underlying disease. True fibrositis can occur without obvious underlying disease and may subside spontaneously, but it can frequently be related to a specific systemic disorder. Disorders commonly associated with fibrositis may be excluded by appropriate laboratory and radiologic studies. A hemoglobin determination, sedimentation rate, latex test, and antinuclear antibody test should be ordered on all patients with diffuse aching and stiffness. If the symptoms of fibrositis persist and remain unexplained, the patient should undergo a general physical examination. Additional laboratory studies, such as a complete blood cell count and screening profile to include a white blood cell count, differential cell count, blood urea nitrogen, serum glutamic oxaloacetic transaminase (SGOT), uric acid, calcium level, urinalysis, and chest roentgenogram are also obtained. Serum protein electrophoresis, thyroxine level, lupus erythematosus cell preparation, and creatine phosphokinase (CPK) determination are often helpful in evaluating fibrositis. According to the definition used here, fibrositis is a clinical syndrome and mayor may not be associated with abnormal results on laboratory tests. For example, if fibrositis is caused by rheumatoid arthritis, the latex test may be positive, or if fibrositis is caused by polymyalgia rheumatica, the sedimentation rate may be very high. On the other hand, in idiopathic fibrositis, results of all of the laboratory tests may be completely normal. Differentiation of Fibrositis and Psychogenic Rheumatism It is especially important to differentiate the aching and stiffness of the fibrositis syndrome, which is often associated with underlying disease, from the aching of the anxious or depressed patient. The terms fibrositis and psychogenic rheumatism have often been confused in the past. Table 2 contrasts the findings in psychogenic rheumatism
Table 2.
Differentiation of Psychogenic Rheumatism from the Fibrositis Syndrome~'
PSYCHOGENIC RHEUMATISM
Vague, generalized complaints; no consistent pattern Nothing helps Wakes up tired not stiff; no gelling Inappropriate attitude (tense, hostile, nervous, defensive) , Symptoms exaggerated On examination patient overreacts with facial grimacing and touch-me-not withdrawal
FIBROSITIS
Specific complaints; consistent pattern Relief with heat, massage, moderate activity, salicylate, and especially steroids Morning stiffness; gelling Appropriate attitude Symptoms appropriate for findings Physical signs correlate with symptoms
*Modified from a presentation by Philip Hench, M.D., of the Mayo Clinic.
436
WILLIAM
P.
BEETHAM, JR.
with those in patients who have true fibrositis. Hench and Boland 5 have pointed out that patients with psychogenic rheumatism are at the mercy of their internal environment and are moody, hostile, anxious, or depressed, whereas patients with fibrositis are at the mercy of their external environment and are influenced by heat, cold, weather, exercise, rest, and medications. Patients with psychogenic rheumatism often have multiple, vague complaints, and, therefore, history taking is often frustrating and requires extra time. Patients with psychogenic complaints may describe "severe pain" but, when questioned as to the type of pain, are vague and actually describe fatigue, weakness, numbness, pressure, fullness, or burning sensations. They are often worried about constipation, rectal itching, mild rashes, tension headaches, eye irritation, or indigestion. The pattern to their symptoms is not consistent. They wake up tired rather than stiff, and nothing seems to give them relief. In contrast, patients with fibrositis have specific complaints with a definite pattern. They feel stiff on arising in the morning and often improve with moderate activity; the stiffness of fibrositis, however, need not be present only on arising in the morning. Gelling may occur; this is a form of aching and stiffness that occurs after inactivity or rest during the day with limbering up afterward. Unlike psychogenic rheumatism, which nothing seems to help, patients with fibrositis are likely to obtain relief with heat, massage, and salicylates. Steriods usually give marked relief in true fibrositis, and even small doses of steroid can produce dramatic improvement of the aching and stiffness associated with polymyalgia rheumatica. Therefore, one should be reluctant to make a diagnosis of fibrositis if steroids fail to give any relief. Patients with psychogenic complaints often have an inappropriate attitude and appear tense, hostile, nervous, defensive, or depressed. On the other hand, the attitude of patients with fibrositis is usually appropriate for the situation or objective findings. Patients with psychogenic complaints often exaggerate. They do not have ordinary pain but terrible or excruciating pain. They may act as though they are in great distress, but these episodes are often of short duration and are not associated with serious complications. Such patients often give the physician the impression that more should be done to relieve their symptoms.
PSYCHOGENIC RHEUMATISM A diagnosis of psychogenic rheumatism depends on the absence of organic disease, the functional nature of complaints, and the presence of anxiety, depression, or neurosis.! The patient with psychogenic rheumatism often fears or resists the physical examination. The patient may have an exaggerated "touch-me-not" reaction that is out of proportion to objective findings. During the physical examination, the neurotic patient tends to overreact by dramatically withdrawing, facial grimacing, groaning, jumping, or crying out. Often the findings on the
FIBROSITIS AND PSYCHOGENIC RHEUMATISM
437
physical examination are inconsistent. For example, percussion, with the examiner's fist over a painful area, may cause considerable withdrawal and facial grimacing if preceded by the question "Does this hurt? ," which implies that it might cause pain. On the other hand, percussion over the same area later may cause no distress at all if the patient is distracted by conversation during examination. Astasia-Abasia and Camptocormia Two forms of hysterical reaction that illustrate specific examples of psychogenic muscular disorders are astasia-abasia ("unable to stand" and "unable to walk") and camptocormia. When patients with astasia-abasia stand up and take a few normal steps, they lurch wildly or stagger in a bizarre manner often crumpling to the floor if unassisted. These patients may actually demonstrate a remarkable ability to make rapid postural adjustments to prevent falling at the wrong time, and this gait may be quite dramatic. The second form of hysterical reaction is camptocormia, which means bent body. This type of hysterical bent back has been seen in soldiers exposed to combat. These patients are often young men who can bend forward but are unable to straighten their backs while standing, though they are able to do so while lying in bed. This condition can be evaluated further by asking the patient to lie down on a tilt table with the back straight. The table is tilted upright, and the patient is requested to walk forward. The patient suddenly finds himself standing upright, much to his own amazement. Both astasia-abasia and camptocormia are genuine psychogenic hysterical reactions to be distinguished from malingering in which the patient deliberately fakes a symptom for a specific purpose.
COMMON PITFALLS IN THE DIAGNOSIS OF FIBROSITIS When obtaining a history for a possible fibrositis syndrome, the physician should try to avoid asking biased questions. It is best if patients volunteer how they feel on arising in the morning. The examiner should start by asking a general question, such as "How do you feel when you first get up in the morning?" or "At what time of day do you feel the worst?" However, when dealing with patients who give vague answers it may be necessary to resort to direct questions such as "Do you feel stiff on arising in the morning?" In this case, the physician must use more caution in evaluating the answer. In some situations, the examiner may be unable to obtain a history of fibroSitis. For example, some patients are poor historians because of senility or language barrier, and therefore it may not be possible to tell if fibrositis is present. In a true fibrositis syndrome that is masked by anxiety or depression, it is not certain how much is anxiety and how much is fibrositis. This is especially true in young women with systemic lupus erythematosus, and, therefore, it is important to obtain appropriate blood tests
438
WILLIAM
P.
BEETHAM, JR.
for lupus in these patients. Patients with severe fibrositis may have apparent muscle weakness secondary to muscle aching and spasm. These patients may be difficult to differentiate from patients with true muscle weakness secondary to muscle disease, such as polymyositis. They require further muscle studies, such as SGOT and CPK enzyme determinations as well as muscle biopsies and electromyographic studies. Myxedema can also cause diffuse aching and stiffness and should be ruled out by appropriate blood tests. Occasionally, the physician will encounter very stoic patients who are so used to discomfort that they will not admit to significant aching or stiffness. Often a good historian will give a very specific description of fibrositis that can be related upon, and this patient should be studied carefully.
THERAPY AND MANAGEMENT The prognosis of fibrositis will depend on the cause. Patients with this syndrome should have follow-up studies at regular intervals while symptomatic, and if an underlying systemic disease appears, appropriate therapy should be started. Patients with mild :fibrositis without obvious underlying disease often improve with reassurance, two aspirin tablets every four hours, and soaks in a hot tub for relief of muscle aching. If aspirin fails to give relief, a trial of nonsteroidal antiinflammatory drugs, such as indomethacin (Indocin), ibuprofen (Motrin), fenoprofen (Nalfon), naproxen (Naprosyn), tolmetin (Tolectin), or sulindac (Clinoril), can be used. Activities are encouraged as tolerated, but rest periods during the day are often helpful. If the fibrositis is caused by polymyalgia rheumatica, polyarteritis nodosa, dermatomyositis, or systemic lupus erythematosus poorly controlled, use of oral steroids would be justified. However, oral steroids, immunosuppressive drugs, penicillamine, and gold should be avoided in patients with fibrositis syndromes unless a specific disease justifying their use can be identified. Patients with mild psychogenic rheumatism do not need antiinflammatory drugs and often improve with reassurance and emotional support. The muscle tension of anxiety may respond to diazepam (Valium), 5 mg, three or four times a day. Mild depression may improve on antidepressants, such as 50 mg of amitriptyline (Elavil), given as a single evening dose before retiring. However, severe emotional distress may require psychiatric evaluation.
SUMMARY Diffuse aching and stiffness may be caused by a fibrositis syndrome or by psychogenic rheumatism. If fibrositis is present, a careful search for underlying disease is made, and appropriate therapy started depending upon the results of all diagnostic studies.
FIBROSITIS AND PSYCHOGENIC RHEUMATISM
439
REFERENCES 1. Bayles, TB: Psychogenic factors in rheumatic diseases. In Hollander, JL, McCarty, DJ,
2. 3. 4. 5. 6.
Jr (eds): Arthritis and Allied Conditions. Philadelphia, Lea and Febiger, 8th ed, 1972, pp 22~238. Beetham, WP, Jr: Fibrositis syndrome. In Conn, HF (ed): Current Therapy. Philadelphia. W B Saunders Co, 1973, pp 744-745. Beetham, WP, Jr: The fibrositis syndrome vs psychogenic rheumatism. Audio-Digest 24 (#2): Jan 19, 1977, Audio-Digest Foundation, Glendale, CA 91205. Hench, PK: Nonarticular rheumatism. In Katz, WA (ed): Rheumatic Diseases: Diagnosis and Management. Philadelphia, J B Lippincott Co, 1977, pp 608-628. Hench, PS, Boland, EW: The management of chronic arthritis and other rheumatic diseases among soldiers of the United States Army. Ann Intern Med 24:808-825 (May) 1946. Smythe, HA: Non-articular rheumatism and the fibrositis syndrome. In Hollander, JL, McCarty, DJ, Jr (eds): Arthritis and Allied Conditions. Philadelphia, Lea and Febiger, 8th ed, 1972, pp 874-884.
605 Commonwealth Avenue Boston Massachusetts 02215
