Personally important to Dr. Wolfe, the 2010 criteria accommodate a spectrum of beliefs regarding the legitimacy of fibromyalgia as a diagnosis. “The new criteria enable physicians who are uncomfortable with the socio-political aspect of fibromyalgia to evaluate patients without having to sign in as a full-time believer in fibromyalgia. Instead of saying, ‘We’re treating fibromyalgia,’ we have patients who have with high levels of fatigue, sleep disturbance, and body pain. We are treating those symptoms.”
Criticisms of the 2010 Criteria
The two primary criticisms of the revised criteria are the removal of the tender point exam and the exclusion of depression from the symptom severity scale. “The new criteria have been misconstrued as saying doctors no longer need to do a physical examination to diagnose fibromyalgia,” says Dr. Goldenberg. “In the 2010 criteria, we explicitly state the need rule out other conditions. In the old criteria, excluding other conditions was only implicitly stated. It’s impossible to determine if someone has a musculoskeletal disorder versus fibromyalgia without touching them. With the new criteria, what we are saying is that 11 of 18 tender points are not necessary to make an accurate diagnosis of fibromyalgia.”
Many in the rheumatology community were displeased at the exclusion of depression from the 2010 fibromyalgia criteria. “The reality is we don’t see happy, healthy people in rheumatology practice. High rates of depression are seen across all chronic diseases including osteoarthritis, lupus, and rheumatoid arthritis,” says Dr. Wolfe. “Depression was excluded because it didn’t improve the specificity for diagnosing fibromyalgia.”
Psychiatrists generally support the decision to exclude depression from fibromyalgia diagnostic criteria. “Given [that] we’re focused on specificity over sensitivity, including depression would not help us to make a more accurate diagnosis for fibromyalgia,” says Rakesh Jain MD, MPH, practicing psychiatrist and clinical researcher from Lake Jackson, Texas. Although depression is not helpful in making an accurate fibromyalgia diagnosis, the committee widely acknowledges depression is still a significant clinical presentation for fibromyalgia. As Dr. Wolfe notes, “depression and fibromyalgia is a chicken–egg scenario. We cannot differentiate if depression is the result of fibromyalgia symptoms or if one cannot have fibromyalgia without depression.”
The tender point exam did not emphasize the major features of fibromyalgia such as the extent of the pain, fatigue, sleep disturbance, multiple somatic symptoms, and cognitive difficulties.
Clinical Utility of the 2010 Criteria
The 2010 ACR criteria with the widespread pain index and symptom severity score have the clinical potential to serve as both a screening tool and a patient management tool. Dr. Clauw would like to see rheumatology and leaders in fibromyalgia position the new criteria as screening criteria for fibromyalgia. Specific to the rheumatology practice, screening is relevant for patients with rheumatoid arthritis, osteoarthritis, and lupus, who have a higher prevalence of fibromyalgia.