To the Editor:

The article by White et al (1) concerning the lack of adverse outcomes by labeling patients with fibromyalgia raises some interesting questions.

An important issue is the lack of a clear meaning of the statement that there is an absence of an adverse effect on long-term clinical outcome by applying the fibromyalgia label, especially when each of the different measurements used may be affected by this label in varying degrees or not at all. Although treatment regimens are not mentioned, it is common to see improvement in symptoms and tender points in fibromyalgia patients over time (2), and especially with multidisciplinary care (3). This may be related more to the natural history of the disorder, the effectiveness of treatment, and/or the different clinical characteristics of subgroups within the population studied (4), rather than to the label used. However, other important variables may be more directly affected by the label as shown by the findings of significantly greater functional limitations at 36 months in the 43 newly diagnosed patients, and the increased trend (although not reaching statistical significance) of total disability claims and pensions in this group. To explain these findings, additional etiologic and amplifying factors need to be studied such as illness perceptions and behavior, personal beliefs about the disorder, and disability motivations, all of which may be more directly influenced by the fibromyalgia label. Furthermore, the significant increase in disability claims (in addition to symptoms and tender points) in the 28 patients in the previously diagnosed group compared to the original 72 patients in the previously undiagnosed group, suggests that there may indeed be a relation of disability factors to the fibromyalgia label, which could interfere with the development of self-efficacy, decrease motivation toward self-management regimens, and retard functional gains. The important point is how this disease label influences patient perceptions related to illness or wellness behaviors, which in turn may determine the chances of disability versus self-improvement.

On a broader scale, label misapplications may be more prevalent in certain cultural environments also affecting clinical outcomes. For instance, in regions such as the rural South in which there is a cultural hesitancy to use psychological labels and a sparsity of available mental health services, in my experience it is common for the symptoms of mental stress, including states of chronic anxiety and depression with widespread pain, to be inappropriately diagnosed and labeled solely as fibromyalgia. This prevents effective management by avoiding the more difficult and time-consuming evaluation and treatment of relevant psychosocial dislocations, results in an increase in the number of patients thought to have fibromyalgia (including those with intractable symptoms that become “medicalized,” predisposing to potential drug dependence and narcotic abuse), and is another example where superficial labeling of patients with this disorder can do more harm than good. On the other hand, there are patients who are not interested in disability or drugs only, and may benefit from receiving a validating, diagnostic label for previously unexplained symptoms, which may help motivate them toward successful self-management.

More studies are needed to further define the many emotional, social, cognitive, biologic, and other variables that comprise the heterogenous syndrome of what is now called fibromyalgia, and the importance of identifying discrete clinical subgroups. It would be more beneficial to consider the “myalgic” component of this condition as just one of a spectrum of symptoms of a disorder of central pain regulation (5) rather than as a disease label derived from peripheral musculoskeletal findings (as defined by the American College of Rheumatology criteria, [6]), which may result in limited clinical appraisals, misleading stereotypes, iatrogenic complications, and poorer outcomes.

Stephen G. Gelfand MD, FACP, FACR*, * Carolina Rheumatology Associates Myrtle Beach, South Carolina.