線維筋痛症の痛みをどうとらえるか : 慢性疼痛のモデル的疾患として(シンポジウム:慢性疼痛の基礎と臨床,2008年,第49回日本心身医学会総会(札幌))  [in Japanese] How to Evaluate the Pain of Fibromyalgia Syndrome : FMS as a Typical Model of Chronic Pain(Symposium/The Mechanism and Practice of Chronic Pain)  [in Japanese]

近年わが国でも注目されてきた線維筋痛症候群(fibromyalgia syndrome;FMS)は,長期間持続する全身の結合織における疼痛と多彩な愁訴を呈する慢性疼痛のモデルともいえる病態であるが,心身症としての側面を濃厚に有している疾患でもある.発症の背景には何らかの遺伝的,生理学的要因に加え,女性の内分泌的な内的環境の変化やライフサイクル上の多彩な心理社会的ストレス要因も大きく関係する.患者の90%以上に発症の時期に一致して手術・事故・外傷・出産・肉体的過労・過剰な運動などのエピソードがあり,天候,環境変化や不安・抑うつ・怒り・強迫・過緊張・焦燥などの心理的ストレスと連動して病態が変動する,強迫,完全性,執着などの性格特性がみられる,など強い心身相関が認められる.患者の尿中セロトニン,ノルアドレナリンの代謝産物である5HIAAやMHPG,骨格筋の解糖系に関与するアシルカルニチンはうつ病患者と同等に低値であり,FMSの痛みや倦怠感,多彩な身体症状,精神症状の背景にモノアミンやカルニチン代謝が関与していることが示唆される.FMSの治療には通常の対症療法が奏効しないため,的確な薬物療法が重要でSSRIやSNRIなどの抗うつ薬,抗けいれん薬,漢方薬などが併用される.さらにストレス緩和のための生活指導や心身医学的な視点からのカウンセリング,認知行動療法など全人的治療が必須である.この考え方はFMSのみならず他の慢性疼痛にも共通しており,薬物や理学的治療法などの「医療モデル」に加え「成長モデル」からアプローチする重要性は変わらないものである.

Fibromyalgia Syndrome (FMS) is one of the common diseases among the chronic pain disorders characterized by long-lasting generalized pain of the fibro-muscular system and various unidentified complaints. Since the onset and clinical course of FMS involve many psychosocial stress factors and disturbed the endocrine system of womanhood in addition to genetic and physiological factors, it is very important to consider the psychosomatic background of the patient with FMS. Ninety percent of the patients were found to have experienced physical strains such as surgery, accident, trauma, delivery, physical overload and excessive exercise. Remarkable personality traits such as anxiety, fear, anger, obsession, depression and sorrow were observed from clinical interviews and psychological tests. For the physiological background, the amount of urinary metabolites such as VMS, MHPG or 5HIAA showed significantly lower than control healthy subjects, which was very similar to the patients with depression. It is suggested that the dysfunction of serotonin and a noradrenalin-mediated descending pain control system and contraction of muscular and vascular systems followed by circulatory disorders may be involved in chronic pain of FMS. Also the low level of serum acyl-carnitine may explain the psychological and physical exhaustion and accumulated fatigue of FMS. As for medication, ordinary analgesics such as NSAIDs are not effective but antidepressants such as SSRI or SNRI often show a remarkable effect. Anticonvulsants and Kampo herbal medicine have also been reported to be effective for chronic pain of FMS. To the problems of psychological stress and personality, counseling and advanced psychotherapy such as cognitive behavioral therapy (CBT) based on "the personal growth model" may be more important rather than "the medical model". Due to the above condition and situation, psychosomatic specialists will be likely to become main practitioners for the treatment of FMS