As reported in previous articles in this series, a survey of over 1000 patients with FMS and CFS showed that prior to their illness fewer than 1% had disturbed sleep, whereas during their illness this rose to over 90 %.1
Sleep disturbance is a key feature of both CFS(ME) and FMS with hormonal influences which have wide repercussions. Consultant psychiatrist Dr Peter White, of London’s St Bartholomews’s Hospital, states “We know that two thirds of CFS patients have sleep disorders”.2
Is This Sleep Disturbance Due to Disturbed Emotions?
A pioneer FMS researcher Dr. Muhammad Yunus has looked at the link between anxiety, stress and sleep disorders and found that while they influence the degree of this symptom they are not the cause in people with FMS (about 20 to 30% of whom he believes do have anxiety/stress influences in their conditions).3
Dr.Yunus has stated, “The central features of FMS are independent of the psychological status and are more likely related to (i.e.resulting from) the FMS itself, although pain severity may be influenced by psychological factors”.
He does not however believe that psychological factors should be ignored in people with FMS because they can be aggravating factors where pain is concerned, precisely as they can in any other painful condition such as rheumatoid arthritis or some forms of cancer. In an attempt to get the focus of physicians corrected Dr.Yunus speaks of the ‘disturbed physician syndrome’ (DPS).
He says, “DPS (that is doctors treating people with FMS) people are troubled because of their preoccupation that FMS patients are psychologically disturbed. It is not the FMS patients who are disturbed it is the physicians who are psychologically disturbed because they ignore the data and whatever data there is they manipulate to say what they want.”
Anxiety can stem from being permanently in pain, chronically tired and with a list of associated symptoms. It can also act as an aggravating factor and therefore deserves consideration in any treatment plan.
Sleep Problems
What has emerged from research into people affected by FMS is that their muscular aches and pains are frequently the result of the same processes which disturb their sleep, that biochemical imbalances related to poor sleep help to create muscular symptoms, so that the poorer the sleep the more pain and fatigue. Whatever disturbs the sleep causes a chain reaction of other problems and is usually unrelated to the person’s psychological status.
Understanding the Sleep Process
In normal sleep we pass, every 90 minutes or so, through alpha brain-wave patterns (stage 1 light sleep) through progressively deeper stages (stage 2,3,4 or beta, gamma, delta – the deepest stage of sleep). These last three stages are also known as non-REM sleep since the rapid eye movement (REM) which occurs during dreaming is absent in them.
Sleep laboratories have found that nearly half of all people with fibromyalgia have disturbed (by intrusive alpha wave periods) delta stages, and wake up feeling as, or more, tired than when they went to bed.
Many of the remainder of FMS patients suffer from other forms of sleep disturbance (see below).
The Growth Hormone Connection
Delta stage sleep is when growth hormone is released by the pituitary gland, as well as immune system repair functions being more active.
Growth hormone, 80% of which is produced during delta stage sleep, has a direct effect on repair and regeneration of muscles. Its deficiency may account for many of the muscular symptoms of FMS.
Growth hormone production can be encouraged by specific dietary strategies such as fasting as well as during deep/relaxation meditation.
How Muscles are Affected
Dr.H.Moldofsky demonstrated how sleep disturbance can upset muscular status when six volunteers had their stage four sleep disrupted for three nights in a row.4
All developed fatigue, widespread aching muscles and specific tenderness on palpation of the sites used to diagnose fibromyalgia. When the same sleep disruption pattern was used on volunteer long distance runners there was no fatigue and no pain.
As we will see, carefully constructed ‘training’ can be an effective method in recovery from fibromyalgia and in some cases of CFS.
Why do people who suffer ‘ordinary’ insomnia not develop fibromyalgia? Studies have show that ‘normal’ insomnia does not involve the same degree of disturbance of delta stage sleep seen in FMS. When normal sleep is disturbed there is often a greater degree of ‘arousal’ or increased neurological excitability than is evident in FMS patients. This is a ‘different’ form of sleep disturbance and does not influence growth hormone production.
‘Brain fog’
Where stage four (delta) sleep is artificially disturbed in volunteers a host of symptoms appear, including cognitive, memory and concentration difficulties. As sleep disturbance continues volunteers become withdrawn and complain of increased muscular and joint tenderness and stiffness. These physical and mental symptoms disappear with a restoration of delta stage sleep for just two nights.
There is also immune depression during periods of sleep disturbance which may partly account for continuous viral problems which many people with CFS(ME)/FMS experience.
Other Sleep Anomalies
Sleep apnoea occurs in around 25% of FMS/CFS(ME) patients.
Myoclonus (‘restless leg syndrome’) affects about 16% of FMS/CFS(ME) patients
Bruxism affects between 10 and 15% of FMS/CFS(ME) patients
A return to a better sleep pattern is clearly important in helping people with fibromyalgia, however, the same treatment is not required for all forms of sleep abnormality!
Circulatory Disturbances in the Brain5,6
Researchers have uncovered changes in brain circulation as well as the biochemistry of the brain in relation to chronic fatigue sufferers (ME) and FMS patients (same picture in both groups).
- Substance P a chemical compound which increases the sensitivity of nerves to pain has been found in raised levels in the cerebro-spinal fluid of people with FMS
- Serotonin has been found to be deficient in people with CFS(ME) and FMS, which has a profound influence on sleep patterns and alterations in pain sensitivity.
- CFS(ME) patients scanned using Positron Emission Tomography (PET) indicate that areas of their brains are under active in uptake of glucose, the brain’s energy supply f. These early findings could explain the ‘foggy’ brain syndrome, poor concentration, in CFS(ME) and FMS.
- The rate of blood flow in the brain has been tested in both normal individuals and CFS(ME) patients using SPECT scanning with results indicating that the patients had poorer circulation to those parts of the brain controlling both memory and the movement of body parts including the muscles.
- Brain Electrical Activity Mapping (BEAM) was used to test CFS(ME) and FMS patients with abnormalities in circulation to the brain (temporal lobes) The researchers found that it was impossible to distinguish between CFS(ME) and FMS patients even if the FMS patients did not report difficulties with memory.
Brain Scan Results7
- PET (Positron Emission Tomography) research has shown that there is a far lower degree of activity in the frontal lobe of the brain of people with CFS(ME) when compared with normal (control) individuals or when compared with a group of depressed patients who also showed some lowering of activity in these areas.
- Dr Jay Goldstein, using SPECT technology, examined 33 patients with CFS, 15 of whom also met the criteria for FMS. Scans showed marked reduction in blood flow in the right hemisphere of the brain, especially amongst FMS patients.
- James Mountz MD and Laurence Bradley, using SPECT, examined the cerebral blood flow of 10 FMS patients and found a decrease in the region of the caudate nuclei (right and left) which is involved in memory and concentration as well as pain regulation functions.
- 100 FMS patients with chronic headaches were examined by Dr.Thomas Romano using SPECT, and 97 were shown to have blood flow imbalances involving reductions in flow to the temporal and frontal regions of the brain.
The Hormone Link
Hypothalamic-pituitary-adrenal axis imbalances can result in changes which are common in CFS(ME) and FMS including:
- an increase in substance P (leading to more pain)
- a decrease in growth hormone production
- a decrease in energy production
Hormonal imbalances are common in these patient populations, for example 40% of FMS patients have premenstrual problems and 10% of people with low thyroid function have FMS.
Dr.Muhammad Yunus sees the imbalance in FMS as partly at least due to a ‘neuroendocrine’ disorder. He points out that pain and other symptoms common to FMS are transmitted through the central nervous system by neurotransmitters such as substance P, which enhances pain transmissions.
On the other end of the spectrum are neurotransmitters which reduce pain such as serotonin as well as derivatives of serotonin, epinephrine and dopamine.
When there is excess substance P and deficiency of serotonin pain will be felt excessively and research has shown that in FMS there is indeed excess substance P in the spinal fluid (three times normal levels) and also that serotonin is very low.
Limbic system: is this the key to the brain’s role in fibromyalgia?8
The area of the brain most affected by poor blood supply seems to involve the limbic system. The network of nerves which are influenced by it can be seen as a computer which processes information arriving from the body, involving both neural messages and hormonal influences. The limbic system modifies and integrates this information with the experience and attitudes the person has acquired, and selects appropriate responses designed to improve the function and survival potentials of the individual.
The limbic system also strongly influences homeostasis as well as the stability of body temperature, mood appetite, sympathetic nervous system function, immune system efficiency; the selection of adaptive responses to stress, memory regulation, much of sleep function, control of hormonal balance as well as a number of thought processes including our emotional and behavioural response to pain.
At its simplest the limbic system controls our degree of pain tolerance as well as having a powerful effect on immune function.
Dr Jay Goldstein believes that the limbic system, if not functioning normally, could be responsible for many of the symptoms seen in FMS and CFS(ME), including the obvious ‘brain fog’ as well as depression, dizziness, tinitus , intolerance to alcohol, nasal allergies, tendency to gain weight, sensitivity to chemical smells and specific foods, breathing irregularities and many more.
He believes that the limbic system disturbance may itself be the result of cytokine production by viral agents as well as cytokines produced during exercise activity.
In support of this theory Dr.Ismael Mena, using SPECT methods, has shown that the blood flow through that part of the brain known as the cerebral cortex, already low in CFS patients, is further reduced rather than increased (as would be normal) after active exercise.2
Causes?
What could cause the brain, or a major element of it, to become hyper-reactive, sensitised, facilitated? Is it simply because of inadequate oxygen/blood supply?
Dr. Jay Goldstein states that, in people with CFS and FMS, the limbic system “isn’t working right. It is too sensitive to certain stimuli; it doesn’t filter them out properly (through a mechanism called sensory gating), and it doesn’t process the inputs correctly either”. But why does this happen?
The theories as to just why the brain and central nervous system are functioning in an unbalanced way are numerous.
Some experts ‘blame’ immune system disturbances which are themselves a result of toxic overload and/or viral activity operating within a pattern of inborn tendencies and susceptibilities.
It seems as though the multiple stresses of life can cause the defence mechanisms of vulnerable people to become activated and ultimately over-burdened, leading to chaotic responses instead of orderly ones.
Summary of Possibilities: Take a Deep Breath and Read On… 9,10,11,12
Researchers have focussed on the commonly observed (in FMS) hormonal imbalances, or the nervous system’s over-excitablity, which itself is influenced by the hormonal neurotransmitters, which are themselves influenced by nutritional and/or toxic and/or infectious (viruses, yeasts, parasites, bacteria) disturbances, which cause undesirable chemicals to be produced leading to even greater immune system stress, as well as bowel dysfunction and associated poor nutrient absorption, resulting in multiple allergy and sensitivity reactions……or there could be abnormal functional patterns such as hyperventilation which can be caused by, or which can cause, profound anxiety, which itself produces fatigue and sleep disturbances and the repercussions of these….. or the causes could stem from poor stress-coping or nutritional imbalances (too little magnesium, calcium, zinc or chromium or perhaps too much sugar?) with the biochemical mayhem that this could cause…. or the constant bombardment of the central nervous system and brain by messages from neural reporting stations in stressed muscles and myofascial trigger points, caused by postural and habitual-use imbalances, could be overloading the pain tolerance thresholds … or the whole complex of symptoms can be seen to be the result of the focussing into the physical body of disturbed mento-emotional patterns making the problem one which should best be treated by a psychiatrist ….or the whole problem could be caused by trauma or silicone implants or tick bites or vaccination or electromagnetic disturbances or a state of depression which is itself caused by all or any of the above… !
Or the cause(s) of FMS could involve something else altogether which remains as yet undiscovered.
Reality
What we have in reality is an imbalance caused by potentially any or all of the factors listed above, or others, in any combination leading to what we have seen as the likely scenario of biochemical, neurohumoral (nerves and hormones acting together) and functional (circulation etc.) factors, impacting on the brain and central nervous system with devastating effects on the way we function with sleep, anxiety, fatigue, pain, digestive and a host of other symptoms emerging.
What is absolutely critical as we move forward to consideration of what treatments may be useful, is to hold onto several very important facts so that we avoid the mistake of trying to treat everything in sight, and focus on doing what is most likely to help the body to help itself to recovery by using a selection of non-specific (‘constitutional’) approaches as well as a medley of possible direct or local symptomatic methods.
The ‘facts’ are that the homeostatic mechanisms can be assisted towards recovery if we:
- a/ remove as many factors as possible which are negatively impacting on the body/mind through stress reduction, adequate wholesome diet, rest and exercise, elimination of infectious yeasts/viruses/bacteria/parasites, replenishment of deficiencies whether nutritional or hormonal, removal of contact with allergens, reduction in excessive muscle tone via bodywork and stretching, normalisation of postural and use imbalances including breathing retraining and so on.
- b/ Modulate immune and general repair functions and develop increased hardiness by use of suitable constitutional (i.e. non-specific) methods including counselling, hydrotherapy, general bodywork, detoxification, deep relaxation.
- c/ Use safe symptomatic treatment including appropriate medication, acupuncture and other symptom oriented methods.
References
1. Fibromyalgia Network Newsletters : October ‘90 through January ‘92 Compendium #2, January 1993, May 1993 Compendium, January 1994, July 1994.
(the Newsleter is highly recommended for information on FMS)
Available from Fibromyalgia Network PO Box 31750, Tucson Arizona 85751-1750 USA
2. Quoted in the Ann Macintyre Interview in ‘INTERACTION’ (Journal of ‘Action for ME’ )No.16 Summer 1994 p20-24(highly recommended for information onME)
Available from PO Box 1302, Wells BA5 2WE, United Kingdom
3. Yunus M . ‘Fibromyalgia and other functional syndromes’ Journal of Rheumatology 16(sup 19)69 1989
4. Moldofsky H Fibromyalgia, sleep disorder and chronic fatigue syndrome Ciba Foundation Symposium 173 Chronic Fatigue Syndrome p 262-270 1993
5. Goldenberg Fibromyalgia, chronic fatigue syndrome and myofascial pain syndrome Current Opinion in Rheumatology 1993;5:199-20810.
6. Bennett R Fibromyalgia and the Facts Controversies in clinical Rheumatism 19(1)February 1993 pp45-56
7. As reported in Fibromyalgia Network (May 1993 Compendium, July 1993, Jan.1994)
8. Goldstein J. Chronic Fatigue Syndrome – the Limbic hypothesis Haworth Medical Press, Binghampton New York, 1993
9. Ediger B. Coping with Fibromyalgia LRH Publications Toronto 1991
10. Joseph Kalik Fibromyalgia – diagnosis and treatment Journal of Osteopathic Medicine Feb 1989 pp10-19
11. Rothschild B Fibromyalgia – an explanation Comprehensive Therapy 1991:17(6)pp9-14
12. Fibromyalgia Network April 1993 p3-5 (report on current tests for FMS)
Also highly recommended for FMS/CFS information is –
The Journal of Muculoskeletal Pain, published by Haworth Medical Press, 10 Alice Street, Binghamptom, New York 13904-1580