Medical Mystery: Chronic pain but no cause

JK was a 50-year-old woman who came to me after suffering from widespread pain for many years. Despite her efforts, she had never received a medical diagnosis that could explain her misery - or effective treatment to address her pain.

She told me she was certain she had rheumatoid arthritis. She said that she was terribly stiff every morning, but that her joints were not swollen. Actually, she said, her pain didn't involve just her joints - every bit of her body hurt.

She said she was constantly exhausted but had trouble sleeping. She also suffered from depression.

When I examined her, I, too, could see that her joints weren't swollen, but that her muscles were quite tender.

I suspected she had fibromyalgia, a pain-dysfunction syndrome characterized by pain out of proportion to structural damage to the tissues. Researchers believe that in people with this condition, the brain amplifies pain perception, which is why sufferers may have terrible pain but "look fine."

The sleep and mood problems JK described also are frequently associated with fibromyalgia.

There is no cure for fibromyalgia, though there are more treatments available now. Nor are there standard lab tests to diagnose it; physicians instead look at eliminating other possibilities. If pain persists without a physical condition to explain it, fibromyalgia may be diagnosed.

For some fibromyalgia patients, symptoms begin after - sometimes many years after - an emotional or physical trauma. So I gently posed a question she never had been asked before.

I asked my patient whether she had ever been abused or raped. I explained that was the kind of trauma that could later lead to fibromyalgia.

She stared at the floor as she answered. "Yes, I was molested as a young girl."

Her primary-care doctor didn't know about that, she said. Nor did her husband.

"So the only people who know about this are you and me?" I asked.

Yes, she answered, avoiding eye contact.

I asked permission to inform her primary-care doctor of this history, as I felt it was important.

Still staring at the floor, JK nodded.

"Yes, you can tell him," she said quietly. "I don't think he will tell anyone."

In that instant, I realized how much shame she had been carrying around for 40 years. There was no doubt in my mind that her widespread pain, which she thought was due to a form of arthritis, was in fact related to this emotional trauma.

Yet it certainly didn't mean a patient like JK was not suffering real pain. Examples of emotional issues producing physical symptoms are so common they're part of our daily language. How often have you heard of "stress ulcers" and "tension headaches"?

The example I use to explain this concept to patients is blushing - when a subjective emotional/mental stimulus, e.g. the words "your fly is unzipped," produces an objective physical response. As we recognize more and more the interplay between emotions and physical symptoms, mindfulness is becoming a growing asset in the medical world.

In fact, cognitive therapy is a well-established treatment for chronic-pain patients.

I told JK all this and suggested she would be best served by seeking such therapy in addition to medical treatment. Unfortunately, she never returned to my office, so I don't know whether she followed through on my advice.

I continue to ask patients with widespread pain whether they have been abused in any way, and I continue to be amazed by how many of them say yes.

Mark Lopatin is a rheumatologist in Willow Grove and chairman of the Montgomery County Medical Society.

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