Why Do I Hurt Everywhere?
Dr. Michael C. Raucci

The hallmark symptom of fibromyalgia is inexplicable chronic pain. The pain is often found over the majority of the body or the pain may appear to move. Often times certain areas will exhibit pain that is constant and more severe. Sometimes patients will present to their doctors with bizarre symptoms such as pain on only one side of the body (from head to toe) or pain that moves from place to place on a daily basis. These presentations are baffling to most doctors and all too often patients are told that these pains are all in their heads. (Translation: The doctor thinks they are crazy). The doctor who comes to this conclusion is both right and wrong. By stating that the problem is all in the patient's head the doctor is correct. Unfortunately, the doctor who makes this uninformed diagnosis assumes that the patient's problem is psychological when in fact, it is physiological. The problem is produced by neurochemical aberrations in the brain. The condition fibromyalgia is a real, physiological problem. The reason the diagnosis has been so slighted over the past decade is the failure of clinicians to recognize this fact. The typical doctor examines all the aches and pains in the person's body and correctly concludes that there is nothing wrong with those structures and the patient's unusual distribution of pains fits no known disorders. They don't even consider the possibility that it could be a central disorder (coming from the brain).

Fibromyalgia is caused by varying degrees of the four related phenomena listed below.

1. Reduced Serotonin Effectiveness
2. Central Sensitization
3. Peripheral Sensitization
4. Psychosomatic Overlay

Before delving into what these are, it is important to understand exactly what pain is.

In the battle of Santa Cruz, Lord Nelson lost his right arm. Many years later, he experienced pain in the arm which no longer existed (phantom pain). The emergence of these sensations led (Nelson) to proclaim that he now had direct proof for the existence of the soul. For if an arm can survive physical annihilation, why not the whole person? (Ramachandran, 2000)

This anecdote helps to preface a discussion on the brain because it describes a basic tenet of pain. Pain is a function of the brain and it occurs solely in the brain. Lord Nelson left his arm on the battle field. After the battle, if one of Lord Nelson's enemies had stabbed the dismembered arm with his spear in disgust, would Lord Nelson, now miles away have felt any new pain? Of course not. The dismembered arm itself experiences no pain. The unattached arm lacks the ability of perception.

Most amputees experience something called phantom limb pain. It is the perception of pain in the limb that no longer exists. The amputee feels this pain as real as they would pain in their other remaining limbs. But why? Mapped onto our brains is an exact map of our bodies. The relative size of the parts are distorted but every anatomical part which has the ability to perceive pain is represented. When Lord Nelson lost his right arm or when an amputee has his leg removed, the portion of the brain which was mapped for those parts remains intact. Given the right conditions, the neurons in that part of the brain may become excited and the person will feel pain in a nonexistent limb.

How does pain normally occur? We have already identified that pain occurs solely in the brain but clearly something is happening outside the brain. In order to understand the process we need to define a word: Nociception - the neurochemical recognition of tissue injury. When I cut the tip of my left index finger, what is the chronological cascade of events:

1. Cellular membranes are cut
2. Chemicals leak out of those cells
3. Some of those chemicals stimulate nociceptive receptors in the area (nociceptors are receptors that recognize tissue injury and transmit that information to nerves)
4. A neurologic signal is transmitted along a nerve out of the finger, up through the hand, up the arm, into the spinal cord at the level of the neck, and up into the brain into the exact area which represents the tip of my left index finger
5. My brain interprets the information
6. I perceive pain in the tip of my left index finger. I never feel any pain until step 6. If the process is interrupted prior to step 6, I will not feel pain at all.

Reduced Serotonin Effectiveness
Serotonin is the wonder hormone of the brain. When present in normal amounts, it suppresses pain, removes depressive symptoms, and helps to provide complete, rejuvenating sleep. When it is lowered it results in enhanced pain perception, depression, and poor, non-restorative sleep. Some studies have shown some fibromyalgia sufferers have lower than normal amounts of serotonin within the central nervous system (the brain and spinal cord). This finding alone would help to describe the major symptoms of fibromyalgia, however other fibromyalgia sufferers have normal amounts of serotonin. It would appear that in these individuals it is not that they have too little serotonin in the brain but that their serotonin utilization system is not functioning optimally; reduced serotonin effectiveness. Why does this increase the amount of pain? We have already discussed the concept of nociception and tissue injury but there is another aspect of nociception yet unexplained. There are low levels of nociceptive transmission which occur in all people continuously and without tissue injury. All of our nociceptive nerves are sending these baseline transmissions every hour of every day. Normally, when these low level transmissions reach the central nervous system, serotonin and other hormones (endorphins and enkephalins) suppress them below our brains ability to recognize them Thus there is no perception of pain. The reason why anti-depressants are often used to treat fibromyalgia is because they enhance the effectiveness of serotonin. Unfortunately, this has not shown long term effectiveness in the majority of patients.

Peripheral Sensitization
Peripheral means outside of the central nervous system - For our purposes, the rest of the body. Peripheral sensitization occurs to an area of injury when that area's nerve receptors become so irritated that they spontaneously depolarize, sending nociceptive signals to the brain in the absence of any irritation or in the presence of a normally sub-threshold irritation (such as the touch of ones clothes against the skin). This might also be called peripheral hypersensitivity. When this is present, abnormally intense signals are sent to the brain in the absence of a similarly gauged stimulus resulting in the experience of intense pain for no apparent reason. Peripheral sensitization usually occurs only in areas where there was an initial injury. It may spread to adjacent anatomical structures but usually will not spread across the entire body from the site of initial injury. In some fibromyalgia patients, peripheral sensitization will develop over a long period of time in uninjured areas because of a feedback loop from the central nervous system to the periphery after central sensitization has set in.

Central Sensitization
Central sensitization is the process described by Lord Nelson in the aforementioned story. The process by which central sensitization begins varies from person to person. It can begin with a continuous flow of nociception from the periphery, or from a direct physiologic/chemical change at the level of the brain. In either case, an area of the brain, which represents the mapped portion of a part of the body becomes sensitized to pain. Assume its the area representative of the lower back. That area of the brain becomes so sensitive that it no longer requires any nociceptive input from the periphery to create the perception of pain. What begins to happen is the person begins to feel pain in their back when there has been no injury to the back and there are no suprathreshold nociceptive signals being sent. The entire pain phenomena occurs in the brain. The person perceives the pain to be in their back because that is the area of the brain which is engaged in this central self excitation. This phenomena is common to all sufferers of chronic pain, including those with disc herniations an severe soft tissue injuries. What is unique to fibromyalgia is that the area of central sensitization on the brain grows or spreads to include other areas, so that suddenly the person may awaken with pain in their leg despite the fact that they suffered no injury there. It is self excitation of a representative area of the brain which is injured in the periphery which makes fibromyalgia unique. The theory of central sensitization helps to describe those otherwise bizarre findings, such as pain on one entire side of the body and pain that seems to move and change.

Psychosomatic Overlays
Psychosomatosis is the psychological creation of pain. It also occurs solely at the level of the brain and probably involves many of the same neurochemicals but its can be managed with psychotherapy or counseling. When a person feels there is no hope or feels depressed physical symptoms can become enhanced because of psychological overlays. Psychosomatosis by itself is not fibromyalgia. A distinction must be drawn so that person's can be directed towards proper treatment. Psychosomatosis, however, becomes a part of the fibromyalgia condition because of the stress, anxiety and depression associated with chronic pain.

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