Depression with FMS and CFS

Depression can be viewed as both a symptom of fibro and a co-morbid condition. Often when a teenager is finally referred to me for fibro he will report a long-standing depression. Childhood onset depression is slippery and often overlooked. Interestingly enough, symptoms of depression in children and teenagers can include vague aches and pains,[1] particularly headaches and back pain often associated with fibro. As a co-morbid condition, depression is virtually indistinguishable from fibro. Chronic pain and illness are depressing. The question may be whether fibro is a symptom of depression or depression a symptom of fibro, or whether they are simply partners. In either case, it is important to note:

-       Fibro symptoms are known to be alleviated in many cases by SSRIs (like Prozac), SNRIs (like Cymbalta) and other anti-depressant groups[2]

-       SSRIs can cause detrimental side effects and suicidal ideation

-       While psychodynamic therapy might help adults with depression, it is not a good therapeutic choice for an adolescent. Go with CBT.

-       Ritalin can cause or exacerbate depression in teens[3]

-       A severe depression may require hospitalization

 In every case, depression should be taken seriously; it's a serious matter.

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[1] http://www.mayoclinic.com/health/teendepression/DS01188/DSECTION=symptoms Your adolescent - depressive disorders. American Academy of Child and Adolescent Psychiatry. 

[2] http://www.scientificamerican.com/article.cfm?id=new-study-antidepressants-fibromyalgia

[3] Talking Back to Ritalin, Revised : 
What Doctors Aren't Telling You About Stimulants and ADHD
by Peter Breggin, M.D.  Perseus Books, 2001

Diagnosis: Sick of It

Boundary issues

There are a few common themes with young fibro patients, and this is one: Weak boundaries. They tend to be very caring, very empathic with their friends, siblings, parents. They are the family peacemakers, the one the other family members count on to be solidly supportive at all times. Parents see them as very intelligent, caring, hard working, intense. This is the child who cannot let it go. Often the phenomenon of adolescent onset illness can be attributed to a specific stressor; SATs, death of a loved one, illness or absence of a parent; the teen is unable to stop the stressor at the surface and allows it to penetrate her actual physical being. It can also be triggered by an upcoming event; adulthood. This sounds oversimplified. More often than not, however, I see a young woman, 17 years old, in the prime of her life, bright, talented, friendly, pretty, now lying in bed for months at a time. This is simply not a coincidence. The responsibilities of adulthood are daunting enough; for the particularly sensitive adolescent, the competition and drive required to succeed can be so emotionally overwhelming that they manifest physical symptoms. A child will not achieve his developmental task of individuation while lying in bed, needing his parents’ care and attention! This is a complex psychological and medical picture. If your teenager is so stressed out that she is making herself sick, CBT is a good place to start.

Building Trust With Practitioners

I recently treated a teenager who had learned to mistrust her doctors. Though she clearly was suffering from a severely debilitating case of Fibro, many of the physicians she had consulted had been derailed by her obesity. Instead of viewing her weight as a symptom (one of many) of Fibro, the doctors had decided the presenting pathology was obesity. Not only was this unhelpful to the diagnostic process, it delayed treatment and was humiliating and harmful to the already suffering child; somewhere between insensitive and negligent, at the very least it was not good medicine.

As with all things adolescent, trust is imperative in the treatment of Fibro/CFS. The more information the doctors have, the more effective the treatment process will be. The key to gleaning pertinent information from the adolescent patient is good listening. If she feels heard and taken seriously, she will tell you what you need to know. If he feels stupid or judged, he will shut down. In the famous words of Sean Covey (adult son of "7 Habits" author Stephen Covey): Listen more than you talk. You have two ears and one mouth. Duh!

All in your head?

Psyche and Soma

Fibro is, in the strictest sense, psychosomatic; in other words, there is a clear connection between the mind and body. Stress exacerbates symptoms; relaxation and stress reduction alleviate symptoms. However, this is not to say that the pain is not real, or, as many of my cases have been told, “all in your head.” If this were the case, heart disease, stroke and ulcers could also be deemed psychosomatic. It is abundantly clear to the suffering adolescent that stress affects her symptoms. It is in the best interest of all the practitioners involved to not only understand and acknowledge this, but to strengthen awareness of the mind-body link throughout treatment.

While practitioners have come to understand that Fibromyalgia is a real syndrome, there is a social phenomenon that perpetuates the belief that it is a “soft” diagnosis. This myth is often then reinforced by the absence of Fibro’s most common presenting symptom (pain points) in children and teens. The diverse and often varying or shifting symptoms in adolescent onset Fibro further confuse many practitioners. 

The next step is to assemble a treatment team. 

If the teen does not trust the PCP, it may be necessary to find her a doc of her own. In choosing a physician, consider the following statement; Fibromyalgia hurts. It really, really hurts. If the PCP suggests the symptoms are not real, or are in some way exaggerated, this is an indication that this doctor may not be appropriate for your treatment team. Fibro and its symptoms are largely subjective and self-reported. So, Fibro must be treated in the spirit of the great truism of mental health, “everyone’s pain hurts.”

The core of the treatment team should be a cognitive behavioral therapist.

Next: How can CBT help?

Diagnosing a fatigue illness in a teenager

We all know that many teenagers spend a lot of time sleeping. This is not an illness, this is a fact of rapid growth, biorhythms and stress that characterize adolescence. But what if your teen can't get out of bed? Misses school for days, weeks, even months at a time? Complains of vague aches and pains, but never seems to be REALLY sick? He or she could be suffering from adolescent (or childhood) onset FMS or CFS. Truly, it is hard to know.

The diagnostic criteria for FMS, according to the Mayo Clinic, FMS can be diagnosed by presence of 11 0f 18 tender points on the body. There are a number of other symptoms that may or may not be present as well, including:

v    Chronic headaches

v    Migraines

v    Vague aches in arms and legs

v    Sore throats

v    Low-grade fevers

v    Hair loss

v    Weight gain

v    Sleep disorder and non-restorative sleep

v    Fatigue

v    Depression

v    Bladder/bowel pain, urinary frequency

v    Sensitivity to light and/or sound

v    Jaw clenching/TMJ

With teenagers, it's a little more complicated. Very often the main diagnostic symptom of pain in specific places is not present. This fact creates a very confusing picture for both parents and physicians, often leading to misdiagnosis, non-diagnosis and prolonged suffering. As with adult onset FMS or CFS, the illness can follow a specific stressor or more severe illness, or a prolonged period of mild depression and /or vague complaints.

The unfortunate reality is that the diagnosis of FMS or CFS is something of a guessing game, and the guessing involves a process of elimination. (Headaches? Check iron, vision, allergies, blood pressure, etc. ) It is a laborious and frustrating process.

So, if your teenager is not getting out of bed, even for things they love to do, speak to your doctor. The doctor will order a series of standard blood tests, including thyroid function. Once the doc has eliminated any number of life-threatening or serious medical conditions, then we take the next step.

Next time: After the Diagnosis: Now what?

Why is My Teenager So Tired?

The Fatigue Illnesses Meet Adolescence

The teens of today are under more stress than ever before. There is unprecedented competition to get into prestigious colleges and universities; jobs are scarce; dating and marriage are wrought with confusing messages, health risks and pitfalls. Stress-related illnesses are under-diagnosed in adolescents; drugs, alcohol and other forms of self-medication are rampant; depression, eating disorders and self-mutilation are shockingly common; and, things can still get worse.

 Fibromyalgia and Chronic Fatigue Syndrome are increasingly common, stress-induced illnesses that are finding their way into the adolescent population at an alarming rate. They are both painful and debilitating conditions. To date we have developed neither effective diagnostic protocol nor any universally accepted or widely effective treatment for either condition. Teenagers suffering from fatigue illnesses have complex medical and developmental needs. Parents often feel confused by the teen's vague symptoms, lack of medical support and mixed bag of advice.

I am going to walk you step by step through the recovery process, from diagnosis to remission. Fibro can be treated, and your teen can go on to live a happy, healthy and productive life.

Warning! Do Your Homework!

Teenagers are the most techno-savvy among us. It is highly likely that a teenager who has been laid up for any period of time has done extensive research on Fibro and CFS. They have probably diagnosed themselves and mapped out a treatment plan. Do yourself a favor; stay current with the ever-changing pool of treatments and protocol.

As we all know, the Internet is both a blessing and a curse. Yes, there is a lot of information and it is just a click away. On the other hand, posting information is also that same click away. Do not believe everything you read. Start with this:

Fibromyalgia requires multi modal treatment. No one practitioner nor one drug or method is adequate! 

Stay clear of anyone who boasts they know what causes Fibro and knows just how to fix it. In your research you will likely come across anecdotes galore about who was magically cured by what and by whom. If there were in fact one treatment for everyone, you and I would not be on this page.

Next time: Diagnosis