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Tom Bohr

Abstract

The author of this letter responds to an article regarding fibromyalgia in the July/August 2001 issue of The Guides Newsletter and notes an error in the article's assertion that fibromyalgia patients are not more likely to have psychiatric disorders than are other patients with chronic pain (eg, rheumatoid arthritis) because of an error in a previous study (the Alabama fibromyalgia research group). The author of the letter asserts that 27 studies show excess psychopathology in fibromyalgia patients; the few articles that support a diagnosis of fibromyalgia are dated and somewhat weak in terms of methodology. In fact, the Alabama study suffered from referral bias at academic centers and has been refuted by at least two other groups that found that fibromyalgia patients do not seem to have excess psychopathology because the studies were conducted at academic medical centers and therefore suffer from the typical tertiary care referral bias associated with more severely affected patients. The letter writer also highlights the original article's assertion that 14% to 23% of fibromyalgia patients receive a formal diagnosis of somatization. This is a large group of patients, the writer suggests, and a less restrictive diagnosis of “undifferentiated somatoform disorder” or “pain disorder” would increase the incidence. Finally, further discussions of fibromyalgia should address the excess incidence of abuse (sexual, physical, and emotional) during the early life of these patients.

in AMA Guides® Newsletter
Robert J. Barth
and
Tom W. Bohr

Abstract

Complex regional pain syndrome-type 1 (CRPS-1) is a problematic diagnosis of a characteristic burning pain that is present without stimulation or movement, occurs beyond the territory of a single peripheral nerve, and is disproportionate to the inciting event. This article highlights some challenging aspects of the diagnostic formulation for CRPS-1 by the International Association for the Study of Pain (IASP) and provides recommendations to address the issues. First, the terminology, CRPS-1, was created specifically to replace the previous term, “reflex sympathetic dystrophy.” Unfortunately, no gold standard diagnostic tests exist for CRPS-1, and the concept itself has a long and continuing history of controversy, not the least factor of which is the lack of reliable diagnostic schemes. Next, IASP's criteria for CRPS-1 do not standardize the diagnostic process and depart from epidemiologic guidelines, particularly regarding continuing pain, allodynia, or hyperalgesia disproportionate to any inciting event. Further, the IASP protocol overlaps diagnostic criteria for somatoform disorders, eg, those in the American Psychiatric Association's diagnostic manual, DSM-IV-TR. Finally, according to the IASP protocol, the majority of CRPS-1 patients present with symptoms that are indistinguishable from those in the DSM-IV-TR guidelines, and the majority of CRPS-1 cases are indistinguishable from the formal definition of malingering.

in AMA Guides® Newsletter
Robert J. Barth
and
Tom W. Bohr

Abstract

From the previous issue, this article continues a discussion of the potentially confusing aspects of the diagnostic formulation for complex regional pain syndrome type 1 (CRPS-1) proposed by the International Association for the Study of Pain (IASP), the relevance of these issues for a proposed future protocol, and recommendations for clinical practice. IASP is working to resolve the contradictions in its approach to CRPS-1 diagnosis, but it continues to include the following criterion: “[c]ontinuing pain, which is disproportionate to any inciting event.” This language only perpetuates existing issues with current definitions, specifically the overlap between the IASP criteria for CRPS-1 and somatoform disorders, overlap with the guidelines for malingering, and self-contradiction with respect to the suggestion of injury-relatedness. The authors propose to overcome the last of these by revising the criterion: “[c]omplaints of pain in the absence of any identifiable injury that could credibly account for the complaints.” Similarly, the overlap with somatoform disorders could be reworded: “The possibility of a somatoform disorder has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a somatoform scenario.” The overlap with malingering could be addressed in this manner: “The possibility of malingering has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a malingering scenario.” The article concludes with six recommendations, and a sidebar discusses rating impairment for CRPS-1 (with explicit instructions not to use the pain chapter for this purpose).

in AMA Guides® Newsletter