Most FM patients cite pain as a
major cause for disability. Chronic widespread pain is a common finding.
The valid assessment of disability in chronic pain states is notoriously
difficult. The problems that are encountered in assessing the chronic
pain patient are largely related to four issues: 1) pain is a purely subjective
sensation which is usually interpreted in an emotional context, 2) chronic
pain cannot be fully understood in terms of the classical model of disease
that equates pathogenesis with tissue damage or dysfunction, 3) many "non-sick"
people have persistent pain but are not disabled, and 4) disability due
to pain results from a complex interplay between past experiences, education,
income level, work related self-esteem, motivation, psychological distress,
fatigue, personal value systems, ethno-cultural background and the availability
of financial compensation. Rheumatologists are usually more confident
of reliably assessing disability in patients with rheumatoid arthritis
and osteoarthritis; yet important determinants of dysfunction in both
of these diseases are psychosocial issues such as coping style, symptom
focus, anxiety and depression. It is increasingly evident that dysfunction
in chronic pain states is poorly correlated with the severity of pain.
Disabled pain patients usually link impaired functioning to having persistent
pain and cannot conceive of living a normal life as long as they are in
pain. Thus they pursue a fruitless search for a cure which is never realized
-- thus rationalizing their continued disability. In the process they
not only remain dysfunctional, but also over-utilize medical care and
develop increasing personal distress. Interestingly it is the belief that
pain is the major cause of disability, that seems to determine the actual
degree of dysfunction, rather than the absolute level of pain. These psychosocial
and behavioral issues are clearly relevant to some FM patients seeking
disability, but should not be generalized. Each patient has to be thoughtfully
evaluated according to their unique set of circumstances.