The Complete Guide to Fibromyalgia by Sharon Ostalecki

ADHD and Fibromyalgia: Related Conditions?
Joel L. Young, M.D.
Judith Redmond, M.A.

As Gregor Samsa awoke one morning from uneasy dreams, he found himself transformed in his bed . . . . What has happened to me? he thought. It was no dream . . . . Gregor's eyes turned to the window, and the overcast sky - one could hear rain drops beating on the window gutter - made him quite melancholy. What about sleeping a little longer and forgetting all this nonsense, he thought, but it could not be done for he was accustomed to sleep on his right side. . . . he began to feel a dull ache . . . He felt a slight itching up on his belly; . . . he slid down again into his former position. This getting up early, he thought, makes one quite stupid. A man needs his sleep . . . He looked at the alarm clock ticking on the chest . . . It was half-past six o'clock and the hands were quietly moving on, it was even past the half-hour, and it was getting on toward a quarter to seven. Had the alarm clock not gone off? From the bed one could see that it had been properly set . . . Yes, but was it possible to sleep quietly through that ear-splitting noise? Well, he had not slept quietly, yet apparently all the more soundly for that. But what was he to do now? The next train went at seven o'clock; to catch that he would need to hurry like mad . . . "Gregor," said his father now from the left-hand room, "the chief clerk has come and wants to know why you didn't catch the early train. We don't know what to say to him. . . . "But, sir," cried Gregor, beside himself . . . . "A slight illness, an attack of giddiness, has kept me from getting up. I'm still lying in bed. But I feel all right again. I'm getting out of bed now. Just give me a moment or two longer! I'm not quite so well as I thought."

The Metamorphosis by Franz Kafka (1916)

Franz Kafka's 90-year-old description of Gregor Samsa's plight describes familiar territory to patients suffering from fibromyalgia. Gregor awakens one morning finding that he has changed into a beetle laying helplessly on his back, legs and arms flailing in every direction. He struggles heroically to accomplish what is, for most people, a routine and mundane daily event - the simple act of getting out of bed. Gregor is highly motivated to fulfill his duties; he simply cannot.

Like Gregor, fibromyalgia patients have disabling fatigue, muscle pain, depression, and poor sleep. They suffer from unseen but disabling symptoms that result in employment loss, family disapproval, and sometimes, a personal sense of disgrace. Gregor's plight and suffering are seared into the minds of students of introductory European literature. The fibromyalgia patient endures more anonymously.

Mental health professionals receive little training in fibromyalgia and related conditions. Many times therapists learn about their patient's frustration over their chronic pain and fatigue in psychotherapy. Fibromyalgia sufferers feel marginalized by the health care system, and rightly so; in general physicians believe these patients are malingering or drug seeking. Fibromyalgia patients respond to this perceived rejection by seeking alternative care, ranging from chiropractic to vitamin therapy and naturopathic medicine.

We who write this chapter were no exception. Our exposure to the condition resulted from our primary clinical interests, depression and attention deficit hyperactivity disorder (ADHD) in adults. In our psychiatric center, we have had the opportunity to observe patients with these complaints over the past 15 years. We found a strong relationship between long-standing ADHD and the development of chronic pain conditions. This chapter serves to describe this clinical picture.

Surprising Early Findings

Besides reporting classic ADHD symptoms, many of these patients complained of severe muscle pain, unrelenting fatigue, abdominal distress, and intermittent headaches. A proportion had been previously diagnosed with fibromyalgia syndrome (FMS), chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), Epstein-Barr syndrome, or Lyme's disease. A substantial number had histories of migraine headache, tinnitus (ringing in the ears), intercystial cystitis (pain in the urogenital system), and restless legs syndrome (RLS). Most were frustrated; they had consulted many clinicians yet found little lasting relief. Patients heard that their symptoms were unusual or "atypical" to use the medical parlance. Most believed that medical doctors dismissed their complaints after several therapeutic failures.

Initially our clinic dutifully recorded the symptoms of pain and fatigue, but did not specifically address them. Instead, we focused on the patient's primary reason for coming to our clinic - complaints of inattention, distractibility, and hyperactivity. Those who were identified as having ADHD were started on standard medications. Surprisingly, many patients reported improvement in both their ADHD and pain symptoms.

These serendipitous findings forced us to explore the connection between ADHD and fibromyalgia. Are they independent conditions with overlapping symptoms or the same condition dissimilarly labeled by doctors of different specialties? Is it possible that a rheumatologist would diagnose fibromyalgia and a psychiatrist evaluating the identical complaints would diagnose ADHD? Does this relationship explain why similar medications ameliorate seemingly disparate symptoms ranging from distractibility to fatigue and from pain to insomnia? Only careful clinical trials will conclusively answer these questions. This chapter endeavors to explain this relationship.

Although fibromyalgia was the most common chronic-pain condition encountered, we enlarged the definition to include many of the above noted chronic pain conditions we found to be associated with ADHD. Throughout this chapter, we will call this condition the ADHD/fibromyalgia and related symptoms complex (AFRSC).

Disease-State Impact

AFRSC patients are common and have a profound clinical and economic impact. Fibromyalgia is the second-most-reported rheumatologic condition, affecting approximately 4Ð6 million Americans. The Centers for Disease Control estimates that chronic fatigue syndrome affects between 75 and 265 people per 100,000 in the US population. Approximately half a million people in the United States have CFS or a similar condition. More than 8 million Americans have ADHD.¹

Taken together, these conditions have huge societal costs; they result in worker absenteeism, workplace inefficiency, and decreased income. The 2000 Annual Statistical Report on the Social Security Disability Insurance Program reports that 661,900 workers received disability payments. AFRSC may cost $60 billion annually, much of that accounted for in productivity loss, medical treatment, and direct disability payments. The human price on the individual's self-concept and family relationships are less tangible, but profound. An understanding of the individual clinical conditions that comprise AFRSC is essential.

ADHD

Attention deficit hyperactivity disorder (ADHD) is a neuro-behavioral disorder that affects 3Ð9% of school-age children. At least 60% of ADHD children have symptoms that persist into adulthood. By the latest estimate, 4.4% of US adults have the condition. ADHD may not have been diagnosed during the patient's youth, but adults who obtain the diagnosis generally can retrospectively piece together childhood symptoms. ADHD is transmitted genetically, from generation to generation, with a high degree of heritability.

ADHD patients have long-standing symptoms of hyperactivity, impulsivity, and inattention. Although most normal individuals have a smattering of these symptoms, the diagnosis of ADHD is limited to individuals who have the full constellation of symptoms and to those whose symptoms cause impairment in impairment in daily life.