Few topics in rheumatology have generated as much controversy over the last 50 years as fibromyalgia. It is a very common symptom complex of wide variation and reportedly affects up to five percent of the female population. It is characterized mainly by widespread, often “total body” pain. In addition to pain that defies explanation by usual testing methods, patients also suffer from an extensive variety of symptoms that may include but are not limited to daytime fatigue, weight gain, depression, blurred vision, irritable bowel syndrome, severe sleep disruption, dizziness and multiple chemical sensitivities.

Patients are commonly sent to rheumatologists due to arthralgia (joint pain) because a primary care doctor becomes concerned about the development of inflammatory arthritis, lupus or some other autoimmune illness. Until about 20 years ago, many rheumatologists and primary care doctors believed that fibromyalgia was not an illness at all, that it had no basis in physiology and was, in fact, mostly “psychiatric.”

In fact, patients with fibromyalgia were often accused of being lazy, mentally ill or even malingerers trying to find an easy escape from life’s demands. Compounding the cases were a virtually complete lack of objective findings, normal lab results, normal X-rays, and a long list of seemingly unrelated and non-anatomical, and even bizarre sounding complaints that were far out of proportion to objective findings.

However, other rheumatologists believed that the syndrome represented a real malfunction of one or more organ systems. It was their opinion that it would have to be an impossible coincidence for five percent of females to come up with the same set of complaints even if the illness was psychological or psychiatric.

It is clear from even a cursory look that there is a huge variety of symptoms with fibromyalgia and they seemingly involve nearly every organ system in the body. However, if this is a real illness, how could all of the lab tests, X-rays and the physical examination be unrevealing?

If there is a real physiologic malfunction, it has to be in a system that makes contact with all parts of the body. Indeed, in recent years, fibromyalgia research suggests the brain is the location of the abnormalities that may cause the large variety of fibromyalgia symptoms. As we know, the brain has control centers for every organ system and is connected by nerves to every part of the body. Accordingly, it makes sense that a syndrome with such a huge diversity of symptoms could arise from brain and/or nervous system malfunctions. This would also explain why the usual diagnostic tests and X-rays that doctors perform are normal.

However, researchers have been able to use a special kind of MRI, a functional MRI, which actually can detect what areas of the brain are activated from a given stimulus and the given strength of that activation. Using this functional MRI and other advanced research methods, researchers have shown that the brains of those with fibromyalgia respond very differently to pain stimuli than the brains of people without fibromyalgia. In addition, sleep patterns in patients with fibromyalgia are clearly abnormal and this accounts, in part, for the severe sleep patterns suffered by most patients with fibromyalgia.

Accordingly, there is now a large body of widely accepted scientific data that reveal chemical, electrical and functional differences in the way that the brains of those with fibromyalgia handle various inputs and outputs in comparison to normal controls. Due to these recent advances in brain research and the preponderance of evidence for brain malfunction, fibromyalgia is no longer considered imaginary or purely psychological.

Sadly, treatment for the fibromyalgia syndrome is usually unsatisfactory. The challenge of the future is to figure out the exact nature of the malfunctions, why these malfunctions occur and how to treat them. Presently, none of these are very clear.

While there are literally hundreds of claims for successful treatment of fibromyalgia and thousands of Web sites on the subject, there is still no consensus on what treatments, if any, are universally successful. It is likely that no single treatment will be universally successful since all brains are “wired” differently. This adds to the frustration of doctors and patients who must deal with this illness daily. It is common knowledge that a treatment that is effective for one patient’s fibromyalgia may not be effective in other patients. Accordingly, treatment for fibromyalgia must be tailored to fit each individual patient.