Preface 9
Note to fibromyalgia patients 13
Part 1 – Pathophysiology 15
1 We are not alone 17
History 17
Epidemiology 18
Social impact 20
2 Fibromyalgia and central sensitivity syndromes 23
Fibromyalgia symptoms 26
Central sensitivity syndromes 26
3 Diagnosing fibromyalgia 31
Exclusion diagnosis: when you hear hoofbeats, think of zebras 33
When local pain induces systemic pain 36
4 Sleep and fibromyalgia 41
Do all fibromyalgia patients sleep poorly? 43
Does everyone who sleeps poorly have fibromyalgia? 43
Sleep and differences between the sexes 43
Animal models of sleep deprivation (and differences between the sexes) 44
Comparisons between fibromyalgia and other central sensitivity syndromes 45
Does it hurt because you cannot sleep or can’t you sleep because it hurts? 47
Why is sleep bad? 48
5 Fibromyalgia personality and subgroups 51
Fibromyalgia subgroups 52
Type 1 Fibromyalgia 54
Type 2 Fibromyalgia 56
Catastrophizing 57
Schematic summary of part of the pathophysiology of fibromyalgia 59
6 Genetic bases of fibromyalgia 63
Genetic bases of fibromyalgia 65
Gene-environment interaction 68
7 The machine called the nervous system 71
Basic anatomy 72
The development of the central nervous system 80
8 The neuroaffective circuits 85
The limbic system 85
MacLean’s Triune Brain 87
9 Functional principles of a great machine 91
Managing homeostasis 95
10 Maps and the representation of reality 99
Feelings and emotions 103
11 Search and descending pain inhibitory pathways 107
Motivation search system 107
Descending pain inhibitory pathways 111
12 Reward system 115
Satisfaction and satiety 117
The biological importance of hedonistic consumption 121
13 Neurophysiology of stress and its relationships with central sensitivity syndromes 125
Hypothalamic-pituitary-adrenal axis 125
Vasopressin (antidiuretic hormone) 127
Growth hormone (GH) 128
Acute versus chronic stress
The HPA axis and GH in fibromyalgia and central sensitivity disorders 138
The HPA axis in depression 142
14 The immune system and stress 145
The influence of the immune system in the central nervous system – secondary fibromyalgia 146
Introduction to immunology 146
The influence of stress in the immune system 148
Immunological changes in depression 153
Immunological changes in fibromyalgia 154
15 The different forms of the self 157
Protoself 157
The nuclear self 158
The autobiographical self 158
Self 159
Object relations theory 159
The self in Fibromyalgia 161
Insufficiency, forever 165
The insufficiency of the self in motherhood
16 Empathy in fibromyalgia 169
17 When everything goes wrong 175
The role of depression 175
Eros and Thanatos
The bow of Eros and the scythe of Thanatos 181
The self between Eros and Thanatos
Post-traumatic stress disorder 186
18 Control and trust 193
19 Fibromyalgia according to psychology 201
Neuroses 201
Sigmund Freud 202
The correlation between event and personality traits 212
20 A synthesis of the pathophysiology proposal 215
Part 2 – Treatment 221
21 Drug treatment 223
Analgesics 225
Anti-inflammatory drugs 226
Muscle relaxants 227
Tranquilizers 227
Sleep inducers 228
Antidepressants and anticonvulsants 228
Other drugs 230
Drug association 230
The limitations of drug treatment 231
22 General principles in the treatment of fibromyalgia 233
Essential points of the global guidelines 233
Response to standardized treatment 235
23 The imprinting of the self and the theory of psychoeconomics 237
Imprinting and the self 238
Relative psychoeconomic autonomy 243
Activities with social, individual and mixed effects 244
24 Imprinting and the neurophysiology of stress 247
Cognitive therapy 249
Exposure therapy 249
25 The imprinting of pain sensitivity 255
Managing pain by controlling stress 255
Drug approaches to the imprinting of pain processing 256
Non-Medicinal Approaches to the imprinting of pain processing 257
26 The promotion of a good quality sleep 263
Carrot 263
Whip 264
Sleep hygiene 265
Daydreaming 266
Observing the body 267
Other clinical or environmental conditions that impair sleep 267
27 The reintegration of the physical body 271
Negligence and abuse 271
Psychoeconomic inefficiency 272
External intervention 273
Actual risk 274
Restructuring measures 275
28 Conducting a secure transformation 279
A new reality must emerge before the old one disappears 279
Why fibromyalgia patients cannot say “no” 280
Untying the knots 282
29 Guidelines for patients 285
Reinforcement of diagnosis 285
Fibromyalgia is a real disease 286
Mechanisms involved in fibromyalgia 286
Practical recommendations 287
30 The role of the medical doctor 289
ER doctors 290
Ambulatory care physicians 293
31 The role of the psychotherapist 299
Trust and experience 299
Reasons for failing in to providing necessary changes 300
The correction of cognitive aberrations 301
The promotion of mind-body integration 302
32 Miscellaneous physical and technical activities 305
Physical exercises 306
Meditative Movement Therapies 308
Meditation techniques 309
Other activities 310
33 Fragments 315
Isadora 315
Soraia 318
Marina 322
Martin 324
Epilogue 329
Appendices 333
I The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia335
II The modified 2010 ACR Fibromyalgia criteria and severity scales for clinical and epidemiological studies 337
III The McGill Pain Questionnaire – Short version (Brazilian Portuguese) 339
IV The Revised Fibromyalgia Impact Questionnaire (FIQR), Brazilian Portuguese 341
V The SF-36 Questionnaire for the Assessment of Quality of Life (Brazil SF-36) 345
VI Clinical features of fibromyalgia patients 349
References 359