FIBROMYALGIA AND PSYCHOTRAUMA: A CLINICAL CASE AND BRIEF LITERATURE REVIEW

Hicham Guennouni Hassani, Najib Rachid, Jallal EL Ouadoudi and Mahmoud Amine Laffinti Department of Psychiatry, Avicenna Military Hospital, Marrakech, Morocco. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 15 September 2020 Final Accepted: 18 October 2020 Published: November 2020 Fibromyalgia (FM), a chronic disabling disorder causing diffuse musculoskeletal pain, presents strong comorbidity with psychopathological disorders, including post-traumatic stress disorder (PTSD). We report the case of a 35-year old Syrian Refugee, diagnosed with both Fibromyalgia and PTSD related to traumatic events (killed husband, expulsion from home, rape with death threats, difficult socioeconomic situation). An antidepressant treatment combined with psychotherapeutic and psycho-educational intervention led to satisfactory improvements. Considering the clinical case and other related studies, it seems that early management of the traumatic dimension is essential, in order to prevent the chronicity of the suffering and the emergence of psychiatric comorbidities.

Fibromyalgia (FM), a chronic disabling disorder causing diffuse musculoskeletal pain, presents strong comorbidity with psychopathological disorders, including post-traumatic stress disorder (PTSD). We report the case of a 35-year old Syrian Refugee, diagnosed with both Fibromyalgia and PTSD related to traumatic events (killed husband, expulsion from home, rape with death threats, difficult socioeconomic situation). An antidepressant treatment combined with psychotherapeutic and psycho-educational intervention led to satisfactory improvements. Considering the clinical case and other related studies, it seems that early management of the traumatic dimension is essential, in order to prevent the chronicity of the suffering and the emergence of psychiatric comorbidities.

Introduction:-
Fibromyalgia (FM) is a chronic disabling disorder characterized by generalized and diffuse musculoskeletal pain often associated with a heterogeneous symptomatology (chronic and disabling fatigue, sleep disorders, cognitive and functional disorders) [1]. Its prevalence is high: 2% to 5% of the population [2], making it the most frequent chronic diffuse painful disease, with a clear female predominance: 3.4% compared to 0.6% among men; this prevalence increases with age, with more than 7% between 60 and 79 years old [3].
As with all other so-called functional somatic disorders, this complex pathology presents strong comorbidity with psychopathological disorders such as anxiety, depression, and post-traumatic stress disorder (PTSD) [4].
The objective of the present article is to highlight the involvement of the traumatic experience in the genesis of the disorder, and to discuss the importance of considering the psychic dimension at an early stage, in order to prevent somatic suffering chronicity.

Clinical case
Ms. M., is a Syrian refugee in the Zaatari Jordanian camp, a 35 year old housewife, mother of two children, widowed and in extremely difficult socio-economic and family situation. Three years ago, after being expelled from her home, she was a victim of rape with death threats. She has no known medical, surgical or neuropsychiatric history.
The patient has been complaining for 2 years of disabling joint pain, for which she was followed up in rheumatology over 6 months. The tests carried out at Ms. M., including blood tests, standard X-rays, serologies and cerebral CT scan, proved to be normal, and the diagnosis of Fibromyalgia was made.

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Due to the persistence of the symptomatology, a psychiatric opinion was requested. During psychiatric interviews, the patient is sad, her answers are vague and seem to evade questions related to the trauma. The complaints she expresses spontaneously are exclusively somatic. Indeed, the patient says that she has no energy, unable to carry out daily household tasks due to chronic diffuse joint pains, sometimes forcing her to remain in bed.
The patient also evokes moments of revivification of the traumatic event, a strong feeling of guilt, insomnia, and recurring nightmares related to her aggression. A PTSD diagnosis was made, in accordance with the DSM-5.
Ms.M., was put on antidepressant treatment with paroxetine (selective serotonin reuptake inhibitors, SSRI), at a dose of 20 mg / day, combined with anxiolytic treatment over the first few weeks. This treatment was well tolerated and resulted in a gradual improvement in pain symptoms and in an improved sleep.
The antidepressant treatment was maintained at the same dose for six months. It was combined with psychotherapeutic and psycho-educational intervention. Treatment was terminated after 9 months, and follow-up visits up to 12 months were satisfying.

Discussion:-
The question of the link between psychiatry and fibromyalgia is frequently asked and is the subject of current researchs.
As in the literature [3][4][5][6][7][8][9][10][11][12], Ms. M.'s clinical case illustrates the existence of a history of psychological trauma and painful events in people suffering from fibromyalgia. Numerous clinical observations objectify the existence of a serious traumatic history in patients presenting chronic painful symptoms. These painful symptoms are particularly severe when the subject is young at the time of the trauma, or when the trauma has been chronic and recurrent, including primarily physical or sexual aggression [5]. A study including 36 patients treated for fibromyalgia and 29 healthy women showed a significantly higher mean total CTQ (Childhood Trauma Questionnaire) and emotional abuse in FM patients [6]. D'Aoustet al. [7] reported in a study of 76 female war veterans that most cases reported a history of harassment or military sexual trauma (MST), and 46% of these women had symptoms of fibromyalgia.
Other authors have suggested a link between fibromyalgia and post-traumatic stress disorder. Studies by Cohen et al. [8] and Sherman et al. [9] have shown that almost 57% of patients with fibromyalgia have a significant number of PTSD symptoms (avoidance, revivification, anxiety). In addition, women with fibromyalgia and PTSD reported a higher number of past event traumas than men with the same disorder.
An online survey, led in 2018 by Furness et al. [10], gathering qualitative accounts of perceived causes of Fibromyalgia from 596 patients with this pathology, many participants wrote about emotionally traumatic events, such as physical and sexual assaults. The impact of suffering intense or lasting traumatic experiences was exacerbated when patients felt unable to discuss or disclose them.
Toussaint et al. [11] conducted a cross-sectional study in 2016 comparing posttraumatic stress disorder symptoms between 30 patients with fibromyalgia and 30 healthy controls. The study concluded that patients with Fibromyalgia had greater symptoms of PTSD than controls and suggested that healthcare providers should take greater account of the impact of traumas.
The prospective study by Raphael et al. [12] evaluated the hypothesis of comorbidity between fibromyalgia syndrome and post-traumatic stress disorder in a population of 1,312 women before and 6 months after New York September 11 attacks. This study found that the probability of developing PTSD was three times higher in the fibromyalgia group, concluding that there is probably common psycho-biological risk factors. Cohen et al. [8] point out that in fibromyalgia, it is possible that psychic pain, less accepted socio-culturally, may be transformed into physical pain, as a new coping mechanism.

Conclusion:-
The links between fibromyalgia and psychic trauma are convincing, it leads some authors to query the possibility of conceiving fibromyalgia as a somatized form of PTSD.

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In common practice, early management of the traumatic dimension seems essential, in order to prevent the chronicity of the suffering and the emergence of psychiatric comorbidities.