Speculation as to the mechanism whereby some of Dr. St. Amand's fibromyalgia patients experienced improvement while taking guaifenesin. Dr. Robert Bennett Professor Medicine Oregon Health Sciences University -------------------------------------------------------------------------------- There is no doubt that many fibromyalgia patients have been helped by Dr. St. Amand. Thus it is instructive to consider why guaifenesin use was associated with a beneficial outcome in many fibromyalgia patients when used by Dr. St. Amand. This current study provides compelling evidence that guaifenesin has no beneficial action by itself in the treatment of fibromyalgia. Thus the real benefits reported by Dr. St. Amand, over many years, probably have an alternate explanation. This is most likely in the realm of a placebo response aided by powerful cognitive restructuring. Dr. St. Amand was very convinced that uricosuric drugs were of benefit. This was at a time when many fibromyalgia were told that "the problem was all in their head" and nothing could be done. Patients want to hear that they have a legitimate disease for which their is a cure. Dr. St. Amand provided this hope to numerous patients and backed it up by an infectious enthusiasm and a pleasant engaging personality. Gradually many patients started to experience "good days" (as all do at some time) and attributed these to the effects of guaifenesin. This was reinforced by Dr. St. Amand's caveat that worsening (a self fulfilling prophecy in fibromyalgia patients) would precede the promised improvement. The arrival of the promised improvement, with its renewed sense of optimism, would lead many individuals to attempt vocational and avocational experiences that they had given up as being too daunting. Inevitably many patients found that they were indeed more functional than they had thought and took this as a further sign that guaifenesin was all that had been promised. This sequence of events would be a classical example of cognitive changes leading to increased self efficacy. A simple definition of self-efficacy is the enhanced sense of control that derives from a perceived ability to manage symptoms. Interestingly, it is the perception and not the actual capability that determines enhanced self-efficacy and resulting positive behaviors. Four techniques for altering beliefs about self capabilities that can enhance self-efficacy have been described 1. Social persuasion -- health-care professional and peer pressure that persuades people that they have the capability to be more functional. Mastery experiences -- actually performing a previously off-limits activity. Modeling -- observing someone who is similarly afflicted being successful in performing the desired activity. 2. Physiological feedback. This is basically "listening to one's body" by monitoring pain, fatigue, anxiety levels, etc., as a way of optimizing the timing of the new activities. 3. Although self-efficacy enhancement is an exercise in positive thinking, it is the element of "mastery learning" that is the most powerful technique --nothing succeeds like success. In other words, success in performing a function, that was previously off-limits, promotes confidence in repeating that activity and moving on to new activities. success of a few encouraging others. Repetition and mastery of new behaviors using the feedback from small successes, as well as observing successes in one's peers, seem to be critical features in promoting self-efficacy. All these ingredients were present in Dr. St. Amand's approach to treating fibromyalgia patients. Indeed he often used testimonials from "recovered patients" to encourage patients to persevere with the prescribed treatment regimen. In this way Dr. St. Amand has unknowingly used guaifenesin as a powerful focus in a program of cognitive behavioral therapy, in which his empathy, enthusiasm and charisma were the real instruments in effecting a beneficial change.