REVIEW ARTICLE

Fibromyalgia syndrome: A somatoform disorder? W. Häuser1,2, P. Henningsen2 1 Department of Internal Medicine I, Klinikum Saarbrücken, Germany 2 Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, Germany

Correspondence Winfried Häuser E-mail: [email protected] Funding sources None. Conflicts of interest W.H. received a consulting honorarium by Daiichi Sankyo and honoraria for educational lectures by Abbott and Pfizer within the last 3 years. P.H. received honoraria for educational lectures by Eli Lilly and Novartis within the last 3 years. Accepted for publication 13 December 2013 doi:10.1002/j.1532-2149.2014.00453.x

Abstract Background and Objective: Whether fibromyalgia syndrome (FMS) can be classified as a somatoform disorder is under debate. Databases and Data Treatment: Literature searches on the classification of FMS as a somatoform disorder were performed in Medline and in evidence-based guideline databases. Results: A somatoform disorder is defined by medically unexplained somatic symptoms that persist for at least 6 months and lead to a significant impairment of the ability to function in everyday life. The nature and extent of the symptoms or the distress and pre-occupation of the patient cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder. Emotional and psychosocial conflicts play a major role in the onset, severity, exacerbation or maintenance of the physical symptoms. There is disagreement in the FMS research community on the existence of somatic factors sufficiently explaining FMS symptoms. Psychosocial factors play a major role in the onset, exacerbation or maintenance of FMS symptoms in the majority of patients. A biopsychosocial model of interacting biological and psychosocial factors in the predisposition, onset and maintenance of FMS symptoms is more appropriate than the dichotomy between a somatic disease and a mental (somatoform) disorder. Conclusions: The clinical features of FMS and persistent somatoform pain disorder or somatization disorder according to the International Classification of Diseases (ICD)-10 overlap in individuals with chronic widespread pain without specific somatic disease factors. FMS is not synonymous with somatoform disorder.

1. Introduction Fibromyalgia (FM) or fibromyalgia syndrome (FMS) is still a ‘bitterly controversial’ condition (Wolfe, 2009). ‘FM-wars’ have been fought on classification, clinical diagnosis and therapy. With respect to classification, the debates are as follows: Should the complex of symptoms be labelled FM or FMS? Is FM/FMS a reasonable diagnostic label or should FM/FMS symptoms be labelled as somatoform disorder (Häuser et al., 2013b)? © 2014 European Pain Federation - EFIC®

The label FM/FMS is defeated mainly by some representatives of psychosocial medicine (clinical psychology, psychosomatic medicine, psychiatry), who prefer diagnostic labels such as somatoform pain disorder or somatization disorder (Stanford and King, 2009), and by some representatives of general (family) medicine, who prefer the diagnostic label of chronic (widespread) pain (Reed and Herrmann, 2011). Because of the controversies on the topic ‘Should FMS be labelled as a somatoform disorder?,’ the aims of the paper are as follows: Eur J Pain •• (2014) ••–••

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Database Whether fibromyalgia syndrome (FMS) can be classified as a somatoform disorder is under debate. Recent evidence-based guidelines on FMS and somatoform disorders aimed to dissolve the controversy. What does this review add? • The clinical features of fibromyalgia syndrome and persistent somatoform pain disorder or somatization disorder according to the ‘International Statistical Classification of Diseases and Related Health Problems’, 10th Revision, overlap in individuals with chronic widespread pain without specific somatic disease factors. • Fibromyalgia syndrome is not synonymous with a persistent somatoform pain disorder or a somatization disorder.

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b. The guideline group was interdisciplinary and included at least the specialties rheumatology, pain medicine and psychiatry, or psychosomatic medicine or clinical psychology. c. A systematic search strategy was outlined. d. Recognized criteria of classification evidence and recommendations were used. e. The formal process for establishing recommendations (Delphi exercise, panel conference) was outlined. f. Guidelines mixing FMS with other diagnoses, such as chronic fatigue syndrome, myalgic encephalomyelitis or somatoform disorders, were excluded. (2) We searched Medline with the search terms (‘Fibromyalgia’ AND ‘somatoform disorder’) from January 2006 to February 2013.

3. Results (1) to present and critically discuss the different definitions of a somatoform disorder; (2) to provide an overview on the literature on ‘Should FMS be labelled as somatoform disorder?’ and (3) to give some recommendations for clinical care based upon the literature on the classification of FMS.

2. Databases and Data Treatment (1) A search of the US Agency for Healthcare Research and Quality’s American National Guideline Clearing House (NGC) (http://www.guideline.gov), the Scottish Intercollegiate Guidelines Network (SIGN) (http:// www.sign.ac.uk/guidelines/index.html) and the Guidelines International Network (G-I-N) (http:// www.g-i-n.net) was conducted from January 2008 to February 2013 using the keywords ‘Fibromyalgia’ and ‘Fibromyalgia Syndrome’ and ‘somatoform disorder’. Medline was also searched from January 2008 to February 2013 with the search terms ‘Guideline’ [Publication Type] AND ‘Fibromyalgia’[Mesh] and with the search terms ‘Guideline’ [Publication Type] AND ‘somatoform disorder’. A manual search of the guideline bibliographies and contacts to international FMS key opinion leaders was undertaken to verify that all published guidelines were identified. To be included in our analysis, the guidelines had to meet the following criteria (Fitzcharles et al., 2013): a. The guideline was commissioned by a scientific organisation. 2 Eur J Pain •• (2014) ••–••

The search of literature yielded 24 citations (1 in NGC, none in SIGN, 2 in G-I-N and 21 in Medline) for FMS guidelines. FMS opinion leaders reported two FMS guidelines. Three of these met our inclusion criteria: the 2012 Canadian guidelines for the diagnosis and management of fibromyalgia syndrome (Fitzcharles et al., 2013), the guidelines of the Association of the Scientific Medical Societies in Germany on the definition, pathophysiology, diagnosis and treatment of fibromyalgia syndrome (AWMF) (Eich et al., 2012a,b) and the Israeli guidelines for the diagnosis and treatment of the fibromyalgia syndrome (Ablin et al., 2014). The reasons for excluding other hits were as follows: duplications (n = 19); no criteria for establishing level of evidence outlined (n = 1); and not commissioned by a scientific society (n = 1). The search of literature yielded six citations (none in NGC, SIGN and G-I-N, and 6 in Medline) for guidelines on somatoform disorder. One guideline met our inclusion criteria: the 2012 German guideline on non-specific/functional/ somatoform body complaints (Schaefert et al., 2012). The search of literature in Medline for fibromyalgia and somatoform disorder yielded two systematic reviews on somatoform disorders, including FMS which commented on classification (Browning et al., 2011; Tófoli et al., 2011). The Canadian (Fitzcharles et al., 2013) and Israeli (Ablin et al., 2014) guidelines did not comment on the topic ‘fibromyalgia and somatoform disorder’. The Canadian guideline stated that FMS is a clinical construct of pain and other symptoms that cannot be explained by some other illnesses (Fitzcharles et al., 2013). The Israeli guideline (Ablin et al., 2014) classified FMS to be a central hypersensitivity syndrome (Yunus, 2007). Therefore, we focus for the following sections mainly upon the statements of the German guidelines on FMS (Eich et al., 2012a,b) and on functional/ somatoform syndromes (Schaefert et al., 2012).

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4. Terminology

different definitions, together with the lack of uniform views concerning the meaning of somatization and related disorders, were a central issue in studies on these topics.

4.1 ‘Medically unexplained symptoms’ in somatic and psychosocial medicine The plethora of terminology for ‘medically unexplained symptoms’ is a hindrance to care and to research (Schaefert et al., 2012). These symptoms are labelled as ‘functional somatic syndromes’ in somatic medicine. The term ‘functional’ assumes that it is principally the function of the affected organ or organ system that is impaired. The single medical specialities define a variety of functional somatic syndromes for particular complaints (e.g., irritable bowel syndrome, FMS). Functional somatic syndromes are defined by a typical cluster of symptoms (mainly restricted to the focus of interest of the defining specialty), a defined symptom duration (>3 months) and the exclusion of a somatic disease sufficiently explaining the symptoms (Schaefert et al., 2012). Functional somatic syndromes are coded within somatic diseases in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) of the World Health Organization (WHO) (WHO, 1990). FM was defined by the 1990 classification criteria FM of the American College of Rheumatology (ACR) as chronic widespread pain (CWP) with allodynia or hyperalgesia to pressure pain (Wolfe et al., 1990). In 1994, FM was included in Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue (Code M 79.7), of the ICD-10 and thus was classified as a soft-tissue pain syndrome (Ablin et al., 2012). In psychosocial medicine, medically unexplained somatic symptoms meet the criteria of a somatoform disorder if somatic symptoms persist for at least 6 months and lead to a significant impairment of the ability to function in everyday life. The nature and extent of the symptoms or the distress and preoccupation of the patient cannot be fully explained by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder. Emotional and psychosocial conflicts play a major role in the onset, severity, exacerbation or maintenance of the physical symptoms. Somatoform disorders are listed in Chapter V, Mental and behavioural disorders, of the ICD-10 (WHO, 1990). Tofoli et al. (2011) pointed out that the selected systematic reviews of their search of literature highlighted one major difficulty involved in the study of somatization and somatoform disorders: the existence of different definitions for concepts related to somatization within the criteria and categorization of these clinical conditions. The substantial contradictions and © 2014 European Pain Federation - EFIC®

4.2 (Somatoform) pain disorders in the International Statistical Classification of Diseases and Related Health Problems and in the Diagnostic and Statistical Manual of Mental Disorders The understanding of the literature on FMS and somatoform disorders is complicated by some differences in the definitions of somatoform disorders in the ICD-10 of the WHO and of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. The assumption that emotional and psychosocial conflicts play a major role in the onset, severity, exacerbation or maintenance of some chronic pain syndromes dates back to the category ‘psychogenic pain’ of DSM-III, published in 1980. The creation of this category was influenced by the concept of a painprone patient by Engel (1959). The diagnostic category of psychogenic pain was abolished by the ICD-10 and DSM-IV. The ICD-10 category ‘somatoform disorder’ comprises somatization disorder, undifferentiated somatization disorder, hypochondriacal disorder, somatoform autonomic dysfunction and persistent somatoform pain disorder. All these disorders share the following clinical features (WHO, 1990): • Medical findings do not explain the type and the extent of the symptoms or the suffering or emotional involvement of the patient (e.g., a discrepancy between how the patient feels and the medical findings). • Repeated presentation of physical symptoms in conjunction with persistent requests for medical examinations despite repeated negative results (dysfunctional disease behaviour). • Patient resists attempts to discuss the possibility of a psychological cause, even when the beginning and duration of the symptoms are closely related to unpleasant life events, difficulties or conflicts (somatic fixation). • The understanding reached regarding the physical or psychological cause of the symptoms is often disappointing to the patients and doctors (dysfunctional relationship behaviour). • Attention-seeking (histrionic) behaviour of patients. The diagnostic criteria of persistent somatoform pain disorder are listed in Table 1. Eur J Pain •• (2014) ••–••

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Table 1 Criteria of somatoform pain disorder of ICD 10 (F45.4) (WHO, 1990). A. Severe excruciating pain >6 months; and B. No sufficient evidence obtained from adequately conducted somatic testing to explain the symptoms; and C. Occurs in conjunction with emotional conflicts or psychosocial problems that are important causal factors due to their severity; and D. Exclusion of – Psychogenic pain during the course of a depressive disorder or schizophrenia – Pain due to known or psychophysiological mechanisms, such as muscle tension pain or migraine.

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Table 3 ICD-10 criteria of somatization disorder (WHO, 1990). A. At least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found; B. Persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms; C. Some degree of impairment of social and family functioning attributable to the nature of the symptoms and resulting behaviour.

5. FMS: A persistent somatoform pain disorder according to ICD-10? 5.1 Criterion: No medical findings explaining symptoms and suffering

The category ‘somatoform disorders’ of the DSM-IV included conversion disorder, somatization disorder, hypochondriasis, body dysmorphic disorder and pain disorder (American Psychiatric Association Task Force on DSM-IV, 2000). In contrast to the ICD-10, no superordinate clinical features for all subtypes of somatoform disorders were defined. Most notably, the DSM-IV deleted the term ‘somatoform’ and defined only a ‘pain disorder’. However, the diagnostic criteria of pain disorder associated with psychological factors (307.80) of DSM-IV are similar to the criteria of persistent somatoform pain disorder of ICD-10 (see Table 2). Most patients with FMS complain myriads of somatic symptoms (Häuser et al., 2008), which cannot be explained in most cases by somatic diseases. Therefore, FMS has been conceptualized by some psychiatrists as a somatization disorder (Stanford and King, 2009). The DSM-IV and ICD-10 criteria of somatization disorder are similar (see Tables 3 and 4).

Table 2 DSM-IV diagnostic criteria for pain disorder (American Psychiatric Association Task Force on DSM-IV, 2000). A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. Psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance of the pain. D. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). E. The pain is not better accounted for by a mood, anxiety or psychotic disorder and does not meet criteria for dyspareunia.

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Until now, no consistent structural abnormal findings in the musculoskeletal system of FMS patients have been identified (Sommer et al., 2012). The assumption of the absence of peripheral structural abnormalities in FMS patients has recently been challenged: signs of small fibre pathology were found in all 25 FMS patients, but in none of 10 patients with major depression without pain and healthy controls (Üçeyler et al., 2013). However, small fibre pathology would not explain the multiple non-pain symptoms of FMS patients (Uçeyler and Sommer, 2013). Findings on central nervous structural abnormalities in FMS patients can be confounded by co-morbid depressive disorder (Hsu et al., 2009). Table 4 DSM-IV criteria of somatization disorder (American Psychiatric Association Task Force on DSM-IV, 2000). A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment of functioning. B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance. – 4 pain symptoms: a history of pain related to at least 4 different sites or functions – 2 gastrointestinal symptoms: a history of at least 2 gastrointestinal symptoms other than pain – 1 sexual symptom: a history of at least 1 sexual or reproductive symptom other than pain – 1 pseudoneurological symptom: a history of at least 1 symptom or deficit suggesting a neurological condition not limited to pain C. Either – After appropriate investigation, each of the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance OR – When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination or laboratory findings – The symptoms are not intentionally produced or feigned.

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5.2 Criterion: Emotional conflicts or psychosocial problems that are important causal factors due to their severity A systematic review of case–control studies of clinical and population-based samples demonstrated that reports of physical and sexual abuse in childhood, adolescence and adulthood were associated with FMS diagnosis in adulthood. However, the relative risks were only slightly elevated and were comparable to the ones that have been found for abuse and some somatic diseases (Häuser et al., 2011). Working place conflicts were associated with an increased risk of FMS in a prospective cohort study (Kivimäki et al., 2004). Retrospective case studies from clinical facilities reported that severe social stress was temporally related to the development of CWP in 60–80% of patients with FMS (Häuser et al., 2006). Moreover, the association between adverse life events and the onset of CWP has been described in retrospective clinical cohort studies and case–control studies (Van Houdenhove and Egle, 2004). Similarities between FMS patients and patients diagnosed with (somatoform) pain disorders in their reports of childhood adversities (Imbierowicz and Egle, 2013) supported the view of FMS as a somatoform pain disorder in European psychosocial medicine.

5.3 Criterion: Exclusion of depressive disorder Systematic review articles demonstrated that comorbid depressive disorders occur in 30–80% of patients with FMS (Fietta et al., 2007). However, not every patient with depressive disorder reports CWP (Okifuji et al., 2000). Given the well-known overlap of chronic pain and depressive syndromes (Tsang et al., 2008), this exclusion criterion of the ICD-10 seems to be arbitrary.

5.4 Criterion: Exclusion of pain due to known or psychophysiological mechanisms Numerous pathophysiology alterations in FMS patients have been described in cross-sectional studies. However, it is not clear whether these findings are epiphenomena or not. Moreover, their specificity for FMS remains to be clarified (Sommer et al., 2012). Because of growing evidence supporting augmentation of pain processes in these patients, some FMS researchers consider FMS to be a disease of neurogenic origin (Clauw et al., 2011). However, central sensitization can be demonstrated in other chronic pain © 2014 European Pain Federation - EFIC®

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syndromes, such as chronic low back pain (Roussel et al., 2013) or chronic whiplash syndrome (Van Oosterwijck et al., 2013). Psychosocial (‘somatoform’) characteristics, such as pain catastrophizing and/or depression, may contribute to the mechanisms of central sensitization (Roussel et al., 2013). However, anxiety and depressive symptoms were not related to pain sensitivity or cerebral processing of pain in one study (Jensen et al., 2010). A systematic review on neuroimaging studies in somatoform disorders, which included studies with FMS patients, concluded that the neuroimaging literature is not yet sufficient to provide a basis for classification of functional syndromes/somatoform disorders based on pathophysiology findings (Browning et al., 2011) In summary, there is no conclusive evidence that (specific) psychophysiological mechanisms are associated with FMS.

6. The death of somatoform disorder and of physical symptom disorder The DSM-IV and ICD-10 criteria of somatoform disorder have been criticized because of the lack of clarity, inconsistencies and limited validity (HausteinerWiehle and Henningsen, 2012). DSM-V substituted the category of somatoform disorders by a new category ‘Somatic symptom disorder’ (American Psychiatric Association, 2013) (see Table 5). Symptoms may or may not be associated with another medical condition. Thus, the previous diagnostic criterion of the absence of an adequate physical explanation was left. The DSM-V as a whole and the category of somatic symptom disorder (SSD) particularly have been heavily criticized. The British Psychology Society expressed a major concern that ‘clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences . . . which demand helping responses, but which do not reflect illnesses so much as normal individual variation’ (British Psychology Society, 2011). The National Institute of Mental Health criticized the lack of validity of some DSM-V categories. The agency will no longer fund research projects that rely exclusively upon DSM-V criteria (Insel, 2013). The category of SSD can lead to a psychiatrization of people with somatic diseases. From the point of view of somatic medicine, the inconsistency of the category ‘excessive thoughts, feelings and behaviors’ and the risk of mislabelling people with somatic diseases as mentally ill have been highlighted (King, 2013). Many Eur J Pain •• (2014) ••–••

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Table 5 Somatic symptom disorder (SSD) (300.82/F45.1) according to DSM-V (American Psychiatric Association, 2013). A. One or more somatic symptoms that are distressing and/or result in significant disruption of daily life. B. Excessive thoughts, feelings or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: (1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms; (2) Persistently high level of anxiety about health or symptoms; (3) Excessive time and energy devoted to these symptoms or health concerns. C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). Specify if: With predominant pain (previously pain disorder). This specifier is for individuals whose somatic symptoms predominantly involve pain. Specify if: Persistent: A persistent course is characterized by severe symptoms, marked impairment and long duration (more than 6 months). Specify current severity: Mild: Only one of the symptoms specified in criterion B is fulfilled. Moderate: Two or more of the symptoms specified in criterion are fulfilled. Severe: Two or more of the symptoms specified in criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

patients with somatic diseases, such as cancer (Rayner et al., 2011), chronic inflammatory disease, chronic heart or liver failure, report distressing physical symptom such as fatigue, loss of appetite and sleep problems (criterion A of SSD). Who decides based on which criteria that thoughts about the seriousness of one’s symptoms are disproportionate (criterion B1 of SSD)? These concerns are also valid for patients with FMS. In a 2012 survey with a general German population sample, 2.1% of the participants met the symptom criteria of the modified ACR diagnostic criteria (Wolfe et al., 2013) of FMS. Furthermore, 53.8% of FMS subjects reported being bothered strongly or very strongly by a symptom at least one severe somatic symptom in the Patient Health Questionnaire Somatic Symptom Short Form (criterion A of SSD) and 40.4% noted at least one, continuous, life-disturbing problem in the 2010 criteria symptom score (approximation of criterion B of SSD). In addition, 38.5% reported both types of symptoms and thus met the criteria of a mild SSD (Wolfe et al., 2013). There is an intensive debate regarding the classification of ‘medically unexplained somatic symptoms’ in the ongoing revision of the ICD too (Kroenke et al., 2007). The following are the opposing positions: 6 Eur J Pain •• (2014) ••–••

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• Elimination of the somatoform disorder diagnostic category; classification of physical complaints without explaining somatic disease in the chapter ‘somatic diseases’ (not in the chapter ‘mental disorders’) diseases as bodily distress disorders (Fink and Schröder, 2010). In a study with patients from neurological and medical departments and from primary care with different functional somatic syndromes with impairment, the diagnosis of bodily distress syndrome included all patients diagnosed with FMS. The overall agreement of bodily distress syndrome with any of the diagnostic categories of functional somatic syndromes was 95% (Fink and Schröder, 2010) • Preservation of the somatoform disorder category in the chapter ‘mental and behavioral disorders’ with new behavioural criteria based on DSM-V somatic symptom disorder (Hausteiner-Wiehle and Henningsen, 2012).

7. Conclusions The German guideline concluded that the ICD-10 criteria for FMS (ICD-10M79.70) and persistent somatoform pain disorder (F45.40) and somatization disorder (F45.0) overlap and include different clinical characteristics in individuals with CWP without specific somatic disease factors. FMS is not synonymous with a persistent somatoform pain disorder or a somatization disorder. A majority of patients meet one criterion of persistent somatoform pain disorder, namely the association of emotional conflicts or psychosocial problems with the onset or exacerbation of symptoms (Eich et al., 2012a). A dimensional diagnostic approach based on somatic and psychological complaints, psychosocial stressors, disability and subjective beliefs regarding the cause of the illness is more appropriate than the categorical classification of FMS as a somatic disease or a mental disorder (Eich et al., 2012a). Within a multidimensional approach, slight, moderate and severe forms of FMS can be differentiated (Eich et al., 2012a). The severity spectrum ranges from slight forms as single functional syndrome (‘FMS only’) to severe forms, which meet the criteria of multiple functional syndromes (e.g., FMS plus irritable bowel plus interstitial cystitis), of pain disorder associated with psychological factors and a general medical condition (e.g., rheumatoid arthritis plus FMS plus depressive disorder), of persistent somatoform pain disorder or of a somatization disorder. A stepwise treatment approach depending upon the severity of FMS has been proposed by the German guideline (Eich et al., 2012b). This proposal concurs with the recommendation of a stepped care approach for the management of all © 2014 European Pain Federation - EFIC®

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,functional somatic syndromes. Identical treatment strategies have proven effective in various functional somatic syndromes (such as aerobic exercise, antidepressants and psychological therapies) and evidence is increasing that these syndromes share common aetiological factors, pathophysiological mechanisms and psychological features (Henningsen et al., 2007; Schröder et al., 2010). Currently, only a minority of patients with functional somatic syndromes receive evidence-based treatment. The main reasons for this are inappropriate organisation of care, physicians’ lack of knowledge and a widespread neglect of patients’ suffering (Schröder et al., 2010). Most FMS patients, researchers and treating physicians would oppose the concept of FMS as a mental (somatoform) disorder. Most patients and researchers agree on a biopsychosocial concept of FMS, in which biological and psychosocial factors are important in the predisposition, exacerbation and maintenance of FMS symptoms (Häuser et al., 2013b): Childhood adversities may predispose to FMS (Häuser et al., 2011). Major life events and chronic psychosocial stress might trigger the onset of FMS symptoms such as the spread of pain (Van Houdenhove and Egle, 2004). Mental disorders such as depressive disorder (Lange and Petermann, 2011) and post-traumatic stress disorder (Häuser et al., 2013a) have a negative impact on FMS symptoms and disability. Genetic factors predispose to FMS (Arnold et al., 2013). Inflammatory rheumatic disease triggers FMS symptoms (Wolfe et al., 2011). Somatic co-morbidities have a negative impact on FMS symptoms and disability (Wolfe et al., 2011). The wars on FMS (Wolfe, 2009) can be over – give peace a chance (Harth and Nielson, 2009). Author contributions W.H. provided clinical and scientific input in data interpretation, is head of the German guideline group on FMS and is the author of the manuscript. P.H. provided clinical and scientific input in data interpretation, is head of the German guideline group on non-specific/functional/somatoform bodily complaints and is the co-author of the manuscript.

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Fibromyalgia syndrome: a somatoform disorder?

Whether fibromyalgia syndrome (FMS) can be classified as a somatoform disorder is under debate...
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