Rheumatology International

, Volume 27, Issue 11, pp 1005–1010 | Cite as

The classification of fibromyalgia syndrome

  • W. MüllerEmail author
  • E. M. Schneider
  • T. Stratz
Original Article


As has been shown by a number of working groups, primary fibromyalgia syndrome does not represent a single clinical entity. It is possible to distinguish between a subgroup with high pain sensitivity and no associated psychiatric condition, a second and a third subgroup characterized by depression associated with fibromyalgia syndrome, and a fourth group with somatoform pain disorder of the fibromyalgia type. Mild inflammatory processes must be considered as the cause in the first group, while depression is combined with fibromyalgia in the second and the third group. In the fourth group, serious previous or still existing psychological problems or also insufficient coping with illness symptoms must be regarded as the reason for pain chronification. Group 1 benefits from a blocking of the 5-HT3 receptors by means of tropisetron, for example. This does not only affect pain chronification but also the inflammatory process itself. Group 2 and 3 needs antidepressant treatment, whereas the focus should be on psychotherapy in group 4. Groups 1, 2 and 3 will also profit from multimodal physical treatment programs, to a certain extent this applies to group 4 as well. So-called mixed types require a combination of therapeutic measures.


Fibromyalgia Subgroups Tropisetron 5-HT3-receptor Treatment 



We thank Martin Seybold (Ulm), Hsin-Yun Hsu and Dr. Thomas Joos (NMI Reutlingen) for their support in cytokine measurements and G. Trischler (Ulm) for microCRP determinations.


  1. 1.
    Anderberg UM, Martensdottir I, von Knorring L (2000) Citalopram in patients with fibromyalgia—a randomized, double-blind, placebo-controlled study. Eur. J Pain 4(1):27–35PubMedCrossRefGoogle Scholar
  2. 2.
    Arnold LM, Rosen A, Pritchett YL, D`Souza DN, Goldstein DJ, Iyengar S, Wernicke JF (2005) A randomized double-blind placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depression disorder. Pain 119(1–3):5–15PubMedCrossRefGoogle Scholar
  3. 3.
    Bennett R (2004) Fibromyalgia: present to future. Curr Pain Headache Rep 8:379PubMedCrossRefGoogle Scholar
  4. 4.
    Burckhardt CS, O`Reilly CA, Wiens AN, Clark SR, Campbell SM, Bennett RM (1994) Assessing depression in fibromyalgia patients. Arthritis Care Res 7(1):35–39PubMedCrossRefGoogle Scholar
  5. 5.
    Egle UT (2005) Somatoform disorders—an update. MMW Fortschr Med 147(2):6–4Google Scholar
  6. 6.
    Färber L, Stratz T, Brückle W, Späth M, Pongratz D, Lautenschläger J, Kötter L, Zöller B, Peter H-H, Neeck G, Alten R, Müller W (2000) Efficacy and tolerability of tropisetron in primary fibromyalgia—a highly selective and competitive 5-HT3 receptor antagonist. Scand J Rheumatol 29 suppl. 113:49–54CrossRefGoogle Scholar
  7. 7.
    Fiebich BL, Akundi RS, Lieb K, Candalario-Jalil E, Gmeinder D, Haus U, Müller W, Stratz T, Munoz E (2004) Antiinflammatory effects of 5-HT3 receptor antagonists in lipopolysaccharide-stimulated primary human monocytes. Scand J Rheumatol 33:28–32CrossRefGoogle Scholar
  8. 8.
    Gendreau RM, Thorn MD, Gendreau JF, Kranzler JD, Ribeiro S, Gracely RH, Williams DA, Mease PJ, McLean SA, Clauw DJ (2005) Efficacy of milnacipran in patients with fibromyalgia. J Rheumatol 32(10):1975–1985PubMedGoogle Scholar
  9. 9.
    Giesecke T, Williams Da, Harris RE, Cupps TR, Tian X, Tian TX, Gracely RH, Clauw DJ (2004) Subgrouping of fibromyalgia patients on the basis of pressure-pain threshold and psychological factors. Arthritis Rheum. 50(8):2716–2717Google Scholar
  10. 10.
    Hauser W, Bernardy K, Arnold B (2006) Fibromyalgia—a somatoform (pain) disorder? Schmerz 20(2):128–139PubMedCrossRefGoogle Scholar
  11. 11.
    Hudson JL, Pope HG Jr (1996) The relationship between fibromyalgia and major depressive disorder. Rheum Dis Clin North Am 22(2):285–303PubMedCrossRefGoogle Scholar
  12. 12.
    Koeppe C, Schneider C, Thieme K, Mense S, Stratz T, Müller W, Flor H (2004) The influence of the 5-HT3 receptor antagonist tropisetron on pain in fibromyalgia: a functional magnetic resonance imaging pilot study. Scand J Rheumatol 33:24–27CrossRefGoogle Scholar
  13. 13.
    Mease P (2005) Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol 75(S):6Google Scholar
  14. 14.
    Montoya P, Sitges C, Carcia-Herrera M, Izquierdo R, Truyols M, Blay N, Collado D (2005) Abnormal affective modulation of somatosensory brain processing among patients with fibromyalgia. Psychosom Med 67(6):957–963PubMedCrossRefGoogle Scholar
  15. 15.
    Mullington JM, Hinze-Selch D, Pollmacher T (2001) Mediators of inflammation and their interaction with sleep: relevance for chronic fatigue syndrome and related conditions. Ann NY Acad Sci 933:201PubMedCrossRefGoogle Scholar
  16. 16.
    Odeh M (1998) Role of cytokines in rheumatoid arthritis. Drug News Perspet 11:331–341CrossRefGoogle Scholar
  17. 17.
    Oen K, Robinson DB, Nickerson P, Katz SJ, Cheang M, Peschken CA, Canvin JM, Hitchon CA, Schroeder ML, El-Gabalawy HS (2005) Familial seropositive rheumatoid arthritis in north american native families: effects of sharped epitope and cytokine genotypes. J Rheumatol 32(6):983–991PubMedGoogle Scholar
  18. 18.
    O`Malley PG, Balden E, Tomkins G, Santoro J, Kroenke K, Jackson IL (2000) Treatment of fibromyalgia with antidepressants: a metaanalysis. J Gen Intern Med 15(9):659–666CrossRefGoogle Scholar
  19. 19.
    Ploghaus A, Narain C, Beckmann CF, Clare S, Bantick S, Wise R, Matthews PM, Rawlins JN, Tracey I (2001) Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosci 21(24):9896–9903PubMedGoogle Scholar
  20. 20.
    Ploghaus A, Tracey I, Gati JS, Clare S, Menon RS, Matthews PM, Rawlins JN (1999) Diccociating pain from its anticipation in the human brain. Science 284(5422):1979–1981PubMedCrossRefGoogle Scholar
  21. 21.
    Salemi S, Rethage J, Wollina U, Muchel BA, Gay ST, Sprott H (2003) Detection of Interleukin 1-β, Interleukin-6 and tumor necrosis factor α in skin of patients with fibromyalgia. J. Rheumatol 30:148–150Google Scholar
  22. 22.
    Späth M, Stratz T, Neeck G, Kötter B, Hammel B, Amberger CC, Haus U, Färber L, Pongratz D (2004) Efficacy and tolerability of intravenous tropisetron in the treatment of fibromyalgia. Scand J Rheumatol 33:267–270PubMedCrossRefGoogle Scholar
  23. 23.
    Stratz T, Schneider M, Joos T, Hsu HY, Müller W (2006) Are mild inflammatory processes a possible cause of fibromyalgia in a subtype of this syndrome? Br J Rheumatol (submitted)Google Scholar
  24. 24.
    Stratz T, Schochat T, Hrycaj P, Lacki J, Mennet P, Färber L, Schweiger C, Müller W (1994) Die Therapie der generalisierten Tendomyopathie (Fibromyalgie) durch Blockierung der 5-HT3-Rezeptoren. Z Reumatol 53:335–338Google Scholar
  25. 25.
    Stratz T, Schochat T, Färber L, Schweiger C, Müller W (1995) Are there subgroups in fibromyalgia. J Musculoskel Pain 3(suppl.1):15Google Scholar
  26. 26.
    Stratz T, Müller W (2002) Schmerzbeeinflussung durch den 5-HT3-Rezeptor-Antagonisten Tropisetron bei sekundären Fibromyalgien. Fortschr. Med 120:17–20Google Scholar
  27. 27.
    Stratz T, Varga B, Müller W (2003) Beeinflusst die Depressivität den Behandlungseffekt von Tropisetron bei Fibromyalgie-Patienten? Z Rheumatol 62:42–45PubMedCrossRefGoogle Scholar
  28. 28.
    Stratz T, Müller W (2003) Die Fibromyalgie. Phys Med Rehab Kuror 13:108–114CrossRefGoogle Scholar
  29. 29.
    Thieme K, Turk DC, Flor H (2004) Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables. Psychosom Med 66(6):837–844PubMedCrossRefGoogle Scholar
  30. 30.
    Thieme K, Cromnica-Ihle E, Flor H (2003) Operant behavioral treatment of fibromyalgia; a controlled study. Arthritis Rheum 49(3):314–320PubMedCrossRefGoogle Scholar
  31. 31.
    Thomas E, Blotmann F (2001) Are antidepressants effective in fibromyalgia? Joint Bone Spine 69(6):531–533CrossRefGoogle Scholar
  32. 32.
    Wallace DJ, Linker-Israeli M, Hallegua D, Silvermann S, Silver D, Weismann MH (2001) Cytokines play an aetiopathogenetic role in fibromyalgia; a hypothesis and pilot study. Rheumatology 40:743PubMedCrossRefGoogle Scholar
  33. 33.
    Wolfe F, Cathey MA, Hawley DJ (1994) A double-blind placebo-controlled trial of Fluoxetine in fibromyalgia. Scand J Rheumatol 23(5):255–259PubMedGoogle Scholar
  34. 34.
    Zeitz KP, Guy N, Malberg AB, Dirajlal S, Martin WJ, Sun L et al (2002) The 5-HT3 subtype of serotonin receptor contributes to nociceptive processing via a novel subset of myelinated and unmyelinated nociceptors. J Neurosci 22:1010–1019PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  1. 1.Rheumatologische ForschungsabteilungBad SäckingenGermany
  2. 2.Sektion Experimentelle Anästhesiologie, Klinik für AnästhesiologieUniversitätsklinikum UlmUlmGermany
  3. 3.Rheumaklinik Bad SäckingenBad SäckingenGermany
  4. 4.BinningenSwitzerland

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