Beat the Blues: 10 Ways to Happy

Image via WikipediaPeople with fibromyalgia are susceptible to mood disorders, like depression and anxiety, and I'm no exception. I've been dealing with sleep disturbances and anxiety for the last few weeks. I've been waking up every night between 4:30 and 5:30 am. As soon as I realize I'm awake, I get a flush of anxiety and I can't get back to sleep. I've been working with my therapist to figure out the source of my anxiety, which pops up in my dreams and makes it difficult to sleep. Or it could be too much T3 (thyroid hormone) that I'm taking for Thyroid Hormone Resistance Syndrome, so I'm stepping down the T3 to see if my symptoms abate.

Anyway, given my current state of mind, I was intrigued when I saw a link called 10 Ways to Have a Happier Life. Dr. Andrew Weil, Founder and Director of The Arizona Center for Integrative Medicine, wrote a book called Spontaneous Happiness about ways that can help people achieve and maintain happy lives. He says that "happy" does not mean "endless bliss" but "a state of contentment and serenity" from which someone can still have emotional highs and lows, but be able to easily return to a pleasant state of mind. I found it very interesting that I was already practicing all of the first five points in part one and most of the last five in part two.

The anti-inflammatory food pyramid

The first five suggestions include:  

• exercise
• anti-inflammatory diet
• fish oil and vitamin D
• anti-depression supplements
• breathing exercises. 

All are great methods for anyone with fibromyalgia. Exercise is key, especially low impact exercises like water aerobics and walking. Dr. Weil says, "For treatment of depression and anxiety disorders, activities of moderate intensity, like brisk walking, are more successful than very vigorous activity." Systemic inflammation is a problem in FM, so following an anti-inflammatory diet is helpful. My doctor told me to avoid dairy and gluten, which are both inflammatory. Dr. Weil provides an anti-inflammatory food pyramid. Of course, fish oil helps with inflammation and most people are deficient in Vitamin D, so that helps, too. I use SAM-e, a naturally-occurring molecule found throughout the body, as an anti-depression supplement. SAM-e really helps elevate mood. I could feel a difference almost immediately once I started using it. According to Dr. Weil "the usual dosage is 400 to 1,600 milligrams a day, taken on an empty stomach.  Take lower doses (under 800 milligrams) once a day, a half hour before the morning meal; split higher doses, taking the second a half hour before lunch." Also, breathing exercises are key to calming down the revved up autonomic nervous system found in FM patients. We're always in the "flight or fight" mode, even when there is no danger present. Breathing exercises, such as alternate nostril breathing, help keep us calm.

The last five suggestions include: 

• Cognitive Behavioral Therapy (CBT)
• laughter
• limiting media exposure
• forgiveness
• practicing gratitude

Dr. Don Goldenburg, a specialist in fibromyalgia, highly recommended CBT as a way of dealing with the various symptoms of FM. CBT is based on the concept that our thoughts affect how we feel. Personally, I have been working to transform negative thought patterns into positive thoughts and affirmations to help me feel better, and it works to a certain extent. We all know that laughter is the best medicine! Dr. Weil suggests laughter yoga which combines "Unconditional Laughter with Yogic Breathing." That includes both laughter and breathing exercises. As for limiting media exposure, I stopped watching the news long ago. I would get too depressed and upset and decided it just wasn't worth it. I don't have a smart phone and I'm pretty bad about checking Facebook, too. Dr. Weil suggests replacing virtual media time with face to face interactions with other human beings. Forgiveness can be a difficult process and something that I'm working on in my life. Dr. Weil says forgiveness can be cultivated and cites The Stanford Forgiveness Project. Practicing gratitude can also be cultivated. I used to keep a gratitude journal, writing down 5 things I was grateful for each day, but I've fallen out of the practice. Maybe it's time to start it up again:

• I'm grateful that I feel much better than I did six months ago
• I'm grateful that my son will be coming home from college for Thanksgiving
• I'm grateful that the power is on and I can type up this post
• I'm grateful to be writing the holiday gift guide for my local paper
• I'm grateful that no one was hurt in the fender bender I had in a parking lot

What are you grateful for?
 

Related articles

• Dr. Andrew Weil Talks With Dr. Sanjay Gupta About New Book, His Battle With Depression (shoppingblog.com)
• 10 Fabulous Nutrition Tips I Learned from Dr. Andrew Weil (talesfromthelou.wordpress.com)
• Simplicity Decreases Risk of Depression (simpleblackcoffee.com)
• One man's method for managing depression and supporting his well-being (bipolarblast.wordpress.com)

Water Aerobics Saved My Life!

Image via WikipediaThere is nothing better for fibromyalgia than a water aerobics class outdoors on a sunny summer day! During the long New England winter, the pool at my health club is covered with a bubble that traps in the heat, humidity and chlorine fumes! All the gray-haired ladies and I wait anxiously from Labor Day at the beginning of September until Memorial Day at the end of May for that @#$!! bubble to come down. It has been a glorious summer for outdoor water aerobics this year and I'm trying to get in every last day that I can. All too soon, that bubble will go up and we'll have to suffer through another claustrophobic winter. Of course, water aerobics under the bubble is better than no water aerobics at all, but there is no comparison to exercising in the pool outside in the warm weather.

Image by kaysha via FlickrWhen I was first diagnosed with FM, I went to see one of the top docs for fibromyalgia, Dr. Don Goldenberg. He told me that in order to feel better I had to exercise. I couldn't even imagine exercising since I could barely walk around the block without collapsing on the couch. Dr. Goldenberg told me to try water aerobics because the buoyancy of the water takes the pressure off sore joints and muscles. It took awhile to find the right facility, I've been doing water aerobics in one form or another ever since. I started out in the Nifty Fifty class (well before I was 50), which took things pretty slow. But I built up my strength and my endurance and now that I'm over 50 I'm in a very vigorous aqua fitness class that is actually quite challenging. At 40 I could barely walk around the block and at 50 I could climb the ruins at Tulum, Mexico. Exercise, specifically water aerobics, played a big part in my recovery.

Water aerobics literally saved my life and gave me back a semblance of normalcy. A few years ago I saw Dr. Goldenberg for the last time, and he told me - whatever you do, don't stop the water aerobics. I took his advice to heart and I've kept going three times a week - bubble or not! It makes a huge difference in my life and I make it a priority, even on the bad days.

Related articles

• Aqua Aerobics (blog.stephenholtfitness.com)
• Water Exercise for Fibromyalgia: Easing Deep Muscle Pain (webmd.com)

Fibromyalgia Symposium Part III: Optimal Management of Fibromyalgia

It takes a village to raise a child and it takes a team to manage fibromyalgia: primary care providers, rheumatologists, pain specialists, rehab specialists, neurologists, psychologists, social workers and more. In Part III of the symposium Dr. Natalie Boileau spoke about non-pharmacologic treatments and Dr. Goldenberg followed up with an overview of medications for fibromyalgia.

"Medications alone are not enough in this situation."
~ Dr. Don Goldenberg

Dr. Boileau answers questions after the symposium

The Four Step Method to Manage FM:

1) Exercise - this is key!
2) CBT (Cognitive Behavioral Therapy) - psychotherapy that emphasizes the importance of thinking in how we feel
3) Education
4) Medication

General FM Management: avoid excessive invasive testing; regular psychosocial support; focus on the positive; education; partake in pleasurable activities; focus on activity rather than pain; regular exercise; healthy lifestyle; take control; supportive family; set realistic goals; pace yourself; improve sleep

Non-Pharmacologic Management of Fibromyalgia: Dr. Nathalie Boileau, MD
Rheumatologist

 Dr. Boileau presented an interesting slide that outlined non-pharmacologic FM treatments with strong, moderate and weak evidence of their efficacy. That is not to say that the "weak" treatments don't work, rather there is no compelling evidence to prove that they're effective.

Non-pharmacologic FM Strategies:
 
Strong evidence:

• Exercise: increased blood flow to brain improves cognitive abilities, lessens pain, improves sleep and mood
• Cognitive Behavior Therapy: improves pain, fatigue, and mood which can be sustained for several months
• Patient Education/self management: improves pain, fatigue, and quality of life

Modest Evidence:

• strength training, hypnotherapy, bio-feedback, baineotherapy (medicinal bathing), Tai-chi; yoga

Weak Evidence:

• Acupuncture, Chiropractic, Massage Therapy, Ultrasound

No Evidence:

•  Tender point injections, Flexibility exercises

Exercise: The Cochrane Review looked at 20 of 34 random control trials where patients exercised two times a week for twenty minutes in aerobics, strength training and flexibility. Aerobic exercise improved the pain threshold, well-being and physical function. Strength training worked but not as well as aerobic exercise. Dr. Boileau warned that pain intensity goes up when first starting to exercise but then goes down as conditioning improves.

Vicious Cycle: The pain cycle is induced by lack of exercise! First there is pain in the muscle or in other words a muscle spasm, which decreases blood flow and increases lactic acid. The lactic acid is a signal to the brain to increase the muscle contraction which then in turn increases the pain. Exercise increases the blood flow which washes out the lactic acid and breaks the cycle.

One problem with FM patients is the high drop out rate due to fatigue and pain. High intensity exercise creates a high drop out rate so moderate exercise, 55-75% maximum heart rate or MHR, two to four times a week is recommended for FM. To calculate MHR, subtract one's age from 220. Start slowly and gradually increase exercises such as walking, biking or water aerobics. I do water aerobics two to three times a week and it is a life saver!!!!

Yoga and tai chi are also excellent choices. The study showcased in the news about tai chi and FM patients at Tufts University was a study of Dr. Goldenberg's group.The participants were divided into two groups: one group took a one hour tai chi class once a week for 12 weeks and the second group had wellness education and stretching. The tai chi group improved more in overall function and other FM symptoms than the other group.

Cognitive Behavioral Therapy: counseling educates patients about coping strategies for pain and mood disturbances and reduces depression. It teaches patients about realistic goal setting, relaxation techniques, and re-framing thoughts in a positive manner.

Promising New Tool: Neurostimulation An electrical current is sent to the brain's pain centers which results in pain reduction in FM with very few side effects. But more research is needed.

Complimentary medicine, such as acupuncture and chiropractic, as well as supplements  have little evidence to support their benefit. Dr. Boileau suggested trying them to see if they bring relief. If it's not helping within a month, stop the therapy/supplement.

Overview of Fibromyalgia Management : Dr. Don Goldenberg, MD
Chief of Rheumatology, Newton-Wellesley Hospital 

Pharmacological FM Therapies:
 
Strong evidence:

• Antidepressants: tricyclic compounds (amitriptyline); SNRI's and NSRI's (duloxetine)
• Pregabalin

Modest Evidence:

• Tramadol, Gabapentin, SSRI's, Gamma hydroxybutyrate

Weak Evidence:

• Growth hormone, SAMe, Dopamine agonists, 5-HTP

No Evidence:

•  Opioids, corticosteroids, NSAID's, thyroid hormone, benzodiazepine and nonbenzodiazepine hypnotics, guanifenesin

Recommended: While not a cure, medications have shown to reduce pain from an eight to a four on a scale of 1-10. There is no strong evidence that SSRI's alone are helpful. Dr. Goldenberg recommended a combination of 20 mg of Prozac in the morning and 20 mg of Elavil at night, which is much better than either one alone. SNRI's, such as Cymbalta or Savella, are combination drugs that hit both serotonin and norepinephrine and help with pain and fatigue reduction, not just depression. However, they are equally important in FM patients with and without depression. Pregbalin, such as Lyrica, is an anti-sesuire medication but also helps with pain by affecting the nerve endings. These drugs are difficult to use because of side effects such as headaches, nausea, weight gain, edema and dizziness. Start slowly with a low dose and adjust as needed. Patients need to be patient in order to tolerate them.

Not Recommended: Anti-inflammatory drugs, like Advil, don't really work, but may take the edge off. Opioids can heighten pain and were not recommended. In 2008, most people were taking NSAID's, antidepressants and opioids to treat FM although there is no evidence that NSAID's or opioids actually work.

Typical outcomes in FM patients: Outcomes vary and often overlap with other conditions such as lupus, sleep apnea and chronic fatigue. 10-15% are disabled, most have some impingement on work and leisure and some FM clears up completely.

The Future of FM: increase knowledge; early diagnosis; unite multiple constituencies, such as patients, clinicians and administration; bridge specialties such as rheumatology, neurology and pain management; better understanding of pain pathways.

Fibromyalgia Symposium Part II: Mood Disturbance and FM

Dr. Sandhu speaks with symposium attendees

After a break and a light lunch, two of Dr. Don Goldenberg's colleagues presented information about the management of fibromyalgia. Dr. Sandhu spoke about mood disturbances and their treatment with regards to FM, and Dr. Boileau presented non-pharmacologic interventions. Then Dr. Goldenberg wrapped it up with an overview of the best management options. Although audience members filled out index cards with questions for the panel, there was no time for questions and answers - a real missed opportunity, although Drs. Boileau and Sandhu stayed afterward to speak with attendees.

Overlap of Fibromyalgia and Mood Disturbances and the Role of Mental Health Professionals: presented by Dr. Hartej Sandu, MD, Psychiatrist

The relationship between chronic pain and depression is common. In fact, 50% of people with chronic pain of any kind are also depressed; 80% of those with depression present with physical symptoms. There is a much greater prevalence of depression in all chronic illnesses, but especially in pain conditions like FM. The more severe the pain, the more severe the depression. 30% - 50% of FM patients experience depression and anxiety. In fact, the odds rate of mood disturbances are two times higher in FM patients compared to rheumatoid arthritis.

Dr. Sandu emphasized that fibromyalgia is a real condition, as are mood disturbances. The two conditions interact in a way that makes it more complex for both the patients and the medical providers. He presented three theories on the relationship and treatment of chronic pain and mood disturbances:

No. 1: Depression and stress are a by-product of chronic pain. Treatment is part of somatic (physical) medicine.

No. 2: Somatic symptoms are a manifestation of depression and anxiety. Treatment is primarily a psychiatric problem.

No. 3: Somatic and psychological symptoms are related but different reactions to the same stimulus such as genetic, physiologic and environmental factors. Treatment lies in the overlap of psychiatric and somatic medicine, which is where fibromyalgia lies. (Am I depressed because I'm sick or am I depressed as part of my sickness? My experience has been that the depression is physical, i.e. due to sudden drops in serotonin levels, rather than situational or psychological.)

Dr. Sandhu presented the link between depression and pain in the processes of the brain. Sensory pain is felt in the somata sensory areas which are located on the outermost parts of the brain (that's where my brain tumor was located and thus caused pain on my right side). In addition, affective (emotional) pain is processed in several inner parts of the brain, such as the amigdala, the lymbic system (hypocampus is the memory portion of the lymbic system) and the hypothalmus (controls the autonomic nervous system). All of these areas "light up" when people are stimulated with pain, which shows that there are clearly both sensory and emotional/affective components to pain. These two areas affect one another to complete the clinical picture. However, treating depression doesn't affect the sensory areas that light up in the brain.

Neurotransmitters such as serotonin and norepinephrine are the links to dealing with depression, espcially regarding drugs such as the SSRI's, SNRI's. Also, both neurotransmitters are crucial in the descending pain inhibitory pathway, which makes them key chemicals in dealing with both depression and fibromyalgia pain. 

Shared Features of FM and Depression:

• strong genetic predisposition
• serotonin transporter gene 5-HTT
• sleep disturbances
• cognitive disturbances
• history of childhood abuse or stress
• catastrophizing - the tendency to have a negative approach when anticipating the future which leads to a state of perceived helplessness. (I have to admit I can be guilty of this!) This has real significance in compounding the difficulties in both conditions. Treating depression does not decrease pain, but reducing catastrophizing does!

Studies show that patients with major depression have increased activity in the affective pain centers of the brain similar to that of fibromyalgia. Also, anticipation of pain or a sense of helplessness (catastrophising) causes the same stimulation in the affective regions of the brain. In major depression, patients have less of a capacity to regulate and decrease sensory pain.

Subgroups of FM Patients:

Group 1: Psychological Factors Neutral

• low depression and anxiety
• not very tender
• low catastrophizing
• moderate control over pain

Group 2: Psychological Factors Worsening Symptoms

• high depression and anxiety
• tender
• very high catastrophizing
• no control over pain

Group 3: Psychological Factors Improving Symptoms

• low depression and anxiety
• extremely tender
• very low catastrophizing
• high control over pain

It's fruitless to figure out what came first because mood disorders and pain work in unison. The symptoms are real and debilitating. Health care professionals need to work out a treatment approach to address the entire package in a wholistic fashion. Mental health providers should be part of the FM treatment team.

STAY TUNED FOR PART III: OPTIMAL MANAGEMENT OF FM

Fibromyalgia Symposium Part I: Dr. Don L. Goldenberg

Dr. Goldenberg's new ebook:
FIBROMYALGIA: THE FINAL CHAPTER

The Evolution of Understanding Fibromyalgia: 
Dr. Don L. Goldenberg, MD
Chief of Rheumatology
Newton-Wellesley Hospital

While there wasn't much new territory covered, it was an interesting refresher course for me and a good deal of helpful information for my friend who was recently diagnosed with fibromyalgia. Here are some highlights of the Fibromyalgia Symposium hosted by the Arthritis Foundation New England Region and Dr. Don Goldenberg, Chief of Rheumatology at Newton-Wellesley Hospital:

Most interesting quote: "Do not expect to get cured, but expect to get better." Dr. Don Goldenberg

Objective "Proof" of FM: Yes, Virginia, Fibromyalgia DOES exist! On functional MRI's, pain receptive areas of the brain light up more in FM patients showing higher intensity to pain stimulus than a person without FM. Imaging technology is the wave of the future for pain research.

Image via Wikipedia

New Genetic Discovery: The S/S genotype of 5-HTT, the serotonin transporter gene which regulates pain and mood, is more common in people with FM. This genotype also increases the susceptibility to depression after stressful events. Its presence in some FM patients suggest altered serotonin metabolism in at least a subgroup of people with fibromyalgia.

Historical Factoid: Alfred Nobel, scientist and founder of the Nobel Prize, had paralyzing fatigue with rheumatic pains - in other words, fibromyalgia! Nobel said, "I am more seriously ill than my doctors think" to which Dr. Goldenberg replied, "He knows what he's talking about."

All in the Family: If you have fibromyalgia, it is 8.5 times more likely that fibromyalgia runs in your family. My aunt and two female cousins on my paternal grandmother's side also have fibromyalgia.

"Pain Thermostat" set too high: Dr. Goldenberg stressed that fibromyalgia is not a specific disease but a condition like hypertension which should be viewed on a spectrum. In Fibromyalgia patients the "pain thermostat" or "pain volume" is set too high creating a heightened pain response. On the scale between "no pain" on one end, "mild pain" in the middle and "chronic/severe pain" on the other end, FM patients fall on the extreme end of the pain spectrum.

Most interesting website: Recommended by Dr. Goldenberg, knowfibro.com was developed by Lilly, a pharmaceutical company, but provides helpful information about fibromyalgia rather than promoting their products.

Most Interesting Headline: In 2009 three drugs were finally approved by the FDA for treatment of fibromyalgia. The headline in the New York Times read: Drug Approved - IS DISEASE REAL? Dr. Goldenberg's comment to the audience of fibromyalgia patients was, "You guys still have to put up with that."

New e-book: Dr. Goldenberg assured us that we didn't have to take notes because all of his slides are covered in his new 400 page e-book, FIBROMYALGIA: THE FINAL CHAPTER which is available on Amazon for $9.99. The Kindle App is free to download and can be used to view the book on Kindle, i-pad/i-phone or any Mac or PC. So, if you weren't able to attend the symposium, you can still pick Dr. Goldenberg's brain through his e-book.

New Research Project 2011-2012: Dr. Goldenberg has received a grant from Pfizer to find out if early intervention can prevent severe fibromyalgia symptoms in the long-term. Dr. Goldenberg encourages primary care physicians to diagnose fibromyalgia earlier which means less tests, less medications, less specialists and hopefully less long-term suffering.

Overview of Dr. Goldenberg's Presentation:
Chronic widespread pain affects 5-15% of the population. Fibromyalgia, a subset of that group, affects 3-5% of the population around the world. There is no structural basis for fibromyalgia as there is in arthritis or spinal injuries. Fibromyalgia is the most common cause of "hurting all over." FM is not arthritis which is articular pain, both inflammatory (rheumatoid) and non-inflammatory (osteoarthritis). Fibromyalgia is non-articular pain which is soft tissue pain. FM is not considered classically as a "disease" but a functional illness in which there is a dysfunction in the body.

The peak age of onset of FM is between the ages of 35-60 and affects more women than men. However, FM affects all ages and genders and the rate of FM is the same in adolescents as in adults.

Without lab tests to make a diagnosis, FM is diagnosed through symptoms such as widespread pain for more than three months, fatigue, irritability and cognition impairments. The three areas of diagnosis are: 1) no other systematic disease such as lupus or arthritis 2) chronic widespread pain and 3) tender points or trigger points. While the standard diagnosis used to be pain in 11 out of 18 trigger points, that system was too subjective and not used properly by doctors. The American College of Rheumatology Classification Criteria of Fibromyalgia now includes the Widespread Pain Index and Symptom Severity Scale which takes into account more than just the tender points such as fatigue, morning stiffness, numbness and tingling, headaches, irritable bowel, anxiety and depression.

Dr. Goldenberg said that Lyme Disease is a big problem "in this neck of the woods" (pun intended) and felt that chronic Lyme is probably fibromyalgia or chronic fatigue.

The most common scenario for the onset of FM is that a patient was totally healthy then suddenly got fibromyalgia. It can also be present since childhood or be the result of a specific event. It is more common in women than men but that could be a bias on the part of practitioners who are not diagnosing FM in men. However, not only do women have lower tolerance to pain than men (this is true across species as well) but chronic widespread pain occurs 2X more in women than men.

Precipitating factors: There is a genetic component to FM. In fact, it is 8X more common in families. Triggers of FM include the flu or a virus, a motor vehicle accident, stress, childhood abuse or some combination of the above.

Pathophysiology: FM is disordered pain processing, which is due to imbalances in hormones, the autonomic nervous system and the endocrine system. "Stressors" that aggrevate FM include injury, osteoarthritis, infection, PMS, psychological stress, steroid withdrawal and hormonal alteration such as hypothyroid. Menopause does not seem to change the severity of the symptoms. FM is diffuse hyperalgesia, heightened pain response and/or allodynia, pain from normally painless stimuli such as noise. FM patients have 4 to 5X greater pain response than normal individuals. Neural hormones central in stress reaction (fight or flight) which release cortisol are abnormal in FM. However, there is no "treatment" for this with medicaitons.


The set point for stress is higher with FM and can be affected by genetics, gender, another disease, environmental causes, and/or negative life experiences. The higher the set point/the higher the stress, the more pain is experienced. Hopefully that stress point can be reset and brought down.

Non-restorative sleep: FM patients experience Alpha Wave intrusion in which there is no Delta Wave, or restorative, sleep. When the sleep of normal patients was interrupted with noise they began to experience the pain and fatigue present in FM.

STAY TUNED FOR PART II & III: MOOD DISTURBANCES AND MANAGEMENT OF FM

Fibromyalgia Symposium

Dr. Don L. Goldenberg

For those of you in the Boston area, one of the top docs in fibromyalgia treatment and research is holding a Fibromyalgia Symposium on Saturday, April 9th.  The Arthritis Foundation New England Region and Dr. Don L. Goldenberg, Chief of Rheumatology and Director of the Arthritis-Fibromyalgia Center at Newton-Wellesley Hospital, are partners for the symposium to be held from 10-1 at the Westin Hotel in Waltham, MA. Dr. Goldenberg was the second doctor I saw after my diagnosis in 1997 and the first doctor to put me on the path toward recovery. This is only the third symposium he's held in the past 20 years, so it's a wonderful opportunity to hear from him on the current treatments and research for future developments in the field. 

For those of you not in the Boston area, I'll be attending the symposium and blog about what I learn afterward. I'll be your eyes and ears, so if there are any questions that you want to find out, let me know ahead of time. And stay tuned for reports from the symposium. 

Arthritis Foundation New England Region

Arthritis-Fibromyalgia Center at Newton-Wellesley Hospital

Dr. Don Goldenberg