THE PAIN IS ALL IN THE BRAIN By Rinie Geenen My brother-in-law Richard has just started receiving treatment for his fibromyalgia. The rehabilitation program is multidisciplinary. A physiotherapist guides the weekly exercise program, while a physician has prescribed a new medication. In a few weeks, it should become apparent whether this medication is effective or not. Richard also recently attended his first group session with a psychologist. He said little during the session. Richard hates psychological babble. In fact, a few weeks ago, at my wife’s birthday, he left in a fury when my neighbor said, “Fibromyalgia and other such disorders are all in the mind.” Richard recognizes the emotional impact of his pain, and he knows that it is much more difficult to endure pain in times of stress. This could be considered psychological, mental, or “in the mind,” but my neighbor meant something quite different when she said those words. She meant that patients with fibromyalgia have a weak character and that their pain is fake, a figment of their imagination. Without saying precisely these words, she actually asserted that patients with fibromyalgia “and other such disorders” exaggerate, whine too much, and are too lazy to work. These unspoken words made Richard sad and angry. And worst of all, thanks to my neighbor, Richard’s pain became more severe. WORDS HURT My neighbor is very outspoken, albeit poorly informed. In fact, she has both the voice and the intellectual capacity of a baboon. Nevertheless, this time her words did hold some truth. She claimed that fibromyalgia is “in the mind.” And it is. Please don’t misunderstand me. I am not asserting that fibromyalgia is not physical. Fibromyalgia is undisputedly physical. However, it is also “in the mind” because emotional events can affect fibromyalgia (just like any other illness). This point was demonstrated clearly at the party. My neighbor’s comments did not inflict physical damage, but nevertheless caused severe pain. Words hurt. That proves that fibromyalgia is also mental. If someone becomes stressed, irritated, or angry as a consequence of words, the body responds. For example, the stress hormone norepinephrine is released. This hormone may trigger pain. STRESS HORMONES In an experiment by Mexican rheumatologist Martinez-Lavin, norepinephrine was injected in one forearm of patients with fibromyalgia, while an innocuous placebo fluid was injected in the opposite forearm. Neither the physician nor the patients knew which arm received norepinephrine and which received placebo. The experiment demonstrated that injection of the stress hormone induced much greater pain than injection of the placebo fluid. This proves that norepinephrine amplifies pain in patients with fibromyalgia. Anger and stress lead to an increase of norepinephrine. Richard’s annoyance at my neighbor’s comments raised his norepinephrine levels. Likely, it was the raised norepinephrine that evoked his pain. The process was obvious to onlookers, because Richard’s face grew pale as a consequence of norepinephrine-induced vasoconstriction. Actually, both Richard’s and my neighbor’s beliefs were right and wrong. It is impossible that pain is exclusively mental or exclusively physical. Physical problems have a mental impact: the more pain, the worse the mood. And the inverse applies as well. All actions, feelings, and thoughts bring about changes in nerves and hormones. These changes may inflict pain. BACK AT THE PARTY For several reasons it is useful for a psychologist to be part of the multidisciplinary team at the rehabilitation center. The psychologist can help the patient learn to handle the impact of fibromyalgia, to improve the quality of life, and to cope with stress and anger. All this may help Richard to feel and function better in spite of fibromyalgia. At a future party, if my neighbor again asserts that fibromyalgia is all in the mind, Richard could politely inquire what she means. Perhaps she means that all physical occurrences have an emotional side. Conceivably she believes that all thoughts and feelings are accompanied by physical changes. At so much wisdom there is good reason to have a drink together. Most likely, however, my neighbor means that fibromyalgia patients are simply malingering. But even if this is her opinion, it is wise to relax and to continue the festivity in good spirits. Storming out of the party would make sense only if it could change the mind of a baboon. ------------------ Literature Martinez-Lavin M, Vidal M, Barbosa RE, Pineda C, Casanova JM, Nava A. Norepinephrine-evoked pain in fibromyalgia. A randomized pilot study. BMC Musculoskelet Disord 2002;3(1):2. Dr. Rinie Geenen, Ph.D. is assistant professor at the Department of Health Psychology of Utrecht University, Utrecht, the Netherlands. His research focuses on the biopsychosocial aspects of chronic rheumatic conditions. He has written many scientific and professional publications for patients, scientists, and clinicians. *End* Your comments.