Chronic pain, depression, fibromyalgia and chronic fatigue all seem to feed off each other but which came first? What is the root of this debilitation?

This is a difficult question to answer. The etiology of each of these chronic illnesses remains, alas, a mystery that we have yet to conclusively solve.

That being said, it is very important that we solve them. Why? Because baby-boomers (a very large portion of the American population) are headed into geriatric conditions. Among the most common of these is fibromyaligia. It is to pain management, what alzheimer’s and frontotemporal dementia are to neurology.

What we do know is that pain, fibromyalgia, depression and chronic fatigue syndrome often share common symptoms:

  • sleep disturbance (usually long-term)
  • excessive stress levels
  • psychological repercussions/detriments from sleep loss, excessive stress, and other factors
  • reduced capacity for activities of daily living (ADLs), resulting in reduced cardiovascular exercise and resultant hypofitness

All these factors result in:

Fibromyalgia domains[1]

We also know that although the above symptoms seem to correlate with inflammation, research has shown a demonstrated lack of local inflammation in these shared co-morbidities (common co-occurences). In addition, as inflammation does not occur, anti-inflammatories do not help.

Further answers to this question have filled many textbooks (and been part of ongoing debate in pain management) due to unexplained etiology: if we could figure out the biological pathways that develop the disease, we would at least be closer to a definitive understanding of the commonalities between these diseases. We could then address and treat them definitively.

To my knowledge, the closest we have come to a definitive etiology of fibromyalgia is as follows (if someone knows differently, PLEASE correct me):

  • Fibromyalgia can be considered a discrete condition, as well as a construct. This helps explain how/why individuals have multifocal pain and other somatic symptoms in spite of the lack of nociceptive input (i.e., peripheral damage/inflammation) that adequately accounts for the pain.
  • The primary abnormality, identified to date in fibromyalgia and related pain syndromes, is an increased gain (as in a volume control turned up) in central nervous system pain processing (i.e., secondary hyperalgesia/allodynia).
  • It is likely that this “turning up the volume” on pain and sensory processing is in part due to increased levels of excitatory neurotransmitters (e.g., glutamate, substance P), and/or low levels of inhibitory neurotransmitters (serotonin, norepinephrine, GABA, cannabinoids).
  • Analgesics that work well for “peripheral/nociceptive” pain syndromes (e.g., NSAIDS, opioids), are largely ineffective in fibromyalgia.
  • The most effective classes of drugs in fibromyalgia are centrally acting analgesics (e.g., triciyclics, serotonin re-uptake inhibitors, “SNRI”s, and anticonvulsants (calcium channel blockers).
  • Nonpharmacologic therapies such as education, exercise, manual therapy, and cognitive behavioral therapy are very effective in fibromyalgia and are typically underutilized in routine clinical practices. [2]

Diffuse pain (11/18 points on the body) [3]

Diffuse pain (11/18 points on the body – see diagram above) is the hallmark of fibromyalgia, and this is notably absent in depression and chronic fatigue syndrome. It is also absent, in this pattern, in myofascial pain syndrome (MPS), which tends to be more localised, and also tends to be more functionally oriented. In the fibromyalgia patient, the common complaint is that, “I hurt all over.” The tissue feels very soft and broken-down, versus taut bands and knots of MPS. However, they do sometimes coincide. (See Devin Starlanyle and Mary Ellen Copeland’s “Fibromyalgia & Chronic Myofascial Pain.”)

"Fibromyalgia & Chronic Myofascial Pain: A Survival Manual."

As to how this has been established in case studies, please see the below table:

Frequency of Comorbidity in Fibromyaliga[4]

So, what does this all mean?

  • Sleep quality/quantity is interrupted.
  • There is usually a level of sustained stress and psychological distress.
  • There is a discrepancy of diagnostic criteria: pain with fatigue and psychological distress, versus fatigue and psychological distress, versus psychological distress alone. Granted, cases may change over time (see above diagragm) but the primary characteristics of each individual’s case remain unique in these criteria.

To show this in another way, here’s a current diagram for commonalities that would produce these common symptoms:

Neural Influences on Pain and Sensory Processing[5]

This would help to explain the commonalities of:

  • sleep disturbance ~/= fatigue
  • depression
  • low pain threshold (easily triggered pain)
  • functional compromise

In addition, it may explain why:

  • Amitryptaline/Nortryptaline (SSRI) are helpful in treating many of these common symptoms, via increased levels of available serotonin and norepinephrine/noradrenaline levels in overall tissue.
  • Lyrica/Neurontin (Ca Channel blockers) are helpful to treat many of these common symptoms, via reduced central excitability in signal (especially pain signal) processing.

It is agreed, though, in interdisciplinary pain management, that effective therapy for ALL of these conditions MUST include:

  • Appropriate pharmacologic prescriptions, and
  • Cognitive Behavioral Therapy, to learn triggering deactivation and new coping mechanisms: to mediate pain perception and subsequent neuromodulation.

The following is further noted as helpful:

  • Physical therapy: Begin an appropriate “start low, go slow” low-impact cardiovascular exercise program, such as aquatic therapy or other low-impact mechanisms. This maximises tissue metabolism and ultimate tone.
  • Massage therapy: This modality maximises efficiency of circulatory return and tissue metabolism, in order to enable the tissue to respond to functional demands and short/long-term capabilities (much like physical therapy).
  • Acupuncture: This modality reduces overall CNS (central nervous system) hyperactivation and restores CNS stability. Some studies vary as to the effectiveness of this modality, but observed results are more consistent. In practice, it has shown to help with patient’s ability to comply with functional demands, perhaps due to lowering levels of CNS hyperalgesia. [6]

I wish I had more definitive information to convey. In pain management circles, this is what we’ve got so far. Know, however, that we’re working on it, ardently.

I’ll update as I’m able to.


  1. Essentials of Pain Medicine, 3d Edition; 2011; Benson, Raja, et al.; pg. 346
  2. Ibid., pg.350
  3. fibromyalgia points of pain diagram
  4. Weiner’s Pain Management: A Practical Guide for Clinicians (American Academy of Pain Management), 7th edition; 2007; Mark V. Boswell, B. Eliot Cole; pg. 497
  5. Essentials of Pain Medicine, pg.347
  6. What can neuroscience conclude about acupuncture? by Adriano Stephan on CogSci

Why Does Touch Feel Good?

This is an extremely complex and interesting question.  The answer is even more complex.

As mammals, and especially as primates, our bodies and minds have evolved to desire, seek and receive comforting touch. At every stage of our development as individuals, and as part of a community, it is inarguably healthy for our bodies and minds. It is, in fact, integral to our very survival.

I think that, in order for touch to feel good, it must meet two criteria:

  • The person being touched is honestly receptive, in the positive sense, to that touch; and
  • The person providing the touch has the intent to, on some level, provide “comfort” to the person they are touching.  (This can have different connotations for different people in different situations).

“Let’s start at the very beginning; a very good place to start…”

Engaging in comforting touch is something that is a primal driving force for human beings and primates, in addition to all mammals, and (surprisingly) avians. For mammals, it begins in the womb, as the first sensory neural network develops. This neural network then continues as the basis for the development of the central nervous system. This system, of course, is key to experiencing touch, as we can’t feel what we are anatomically and physiologically incapable of feeling. This is shown in a study of warm, comforting touch between married couples [2]. We require comforting touch from the moment of birth, through the entirety of our lives, and even up to the moment of death. Whether we receive that touch or not has a great impact on our overall well-being.

A great deal of research has determined that our bodies and minds require such touch in order to function properly. However, the variables in development regarding neurotransmitter levels and cultural parameters involving touch are still being studied in depth. The neurotransmitter/hormone oxytocin has been dubbed both the “love hormone” and the “cuddle hormone”, because it becomes highly expressed in the brain during comforting and/or erotic touch. Endorphins, the “feel-good” neurotransmitter/hormone is also highly present during physical interactions that make us psychologically or physically comforted or “attended to.” [3]

The differing parameters of sensory sensitivity levels have been accurately and somewhat humorously depicted in the following educational pictogram of the sensory “homunculus”:

Somatic Sensory Complex ("Why Does Touch Feel Good?")

(Image credit:

The human sensory net‘s “input parameters” are heavily loaded in favor of areas specifically developed and utilized in various stages of life, which translates functionally into sensory systems required for learning, and ultimately, survival.


What specific examples can be found in different stages of life?

As a fetus:

– touch of skin into the amniotic fluid, sac, womb, and surrounding/enveloping anatomy/physiology, to determine spatial parameters, due to the developmental nature of the integumentary (skin) system, in primary relation to the development of the central nervous system.

“From early days,
Beginning not long after that first time,
In which, a Babe, by intercourse of touch,
I held mute dialogues with my Mother’s heart
I have endeavour’d to display the means
Whereby this infant sensibility,
Great birthright of our Being, was in me
Augmented and sustain’d”
– William Wordsworth
The Prelude, 1850, II, 1. 265-272


As a newborn:

  • Touch and smell, predominantly, of the mother (or whatever caretaker is most present)
  • Rooting mechanisms in physiological/psychological reaction and behavior, in order to find FOOD
  • Regulation of heat/cold independent of the mother

If any of these needs are not met, discomfort will result, and subsequent developmental, psychological, and behavioral complications will occur.


Through early life, ages 1-12:

Comforting touch is absolutely required for positive and functional development of the body and mind of the toddler, through to the adolescent.  Positive, comforting touch from a parent or primary caregiver forms sensory feedback associations in the body and mind that set the course for positive inter-relational associations in their future, including dating, mating, sex, and parenthood.  The effect of early comforting touch has been shown to help with early learning of physical comforting of friends, bonding of friends, development of communication with known or potential friends, and simple nonverbal, interpersonal communication (via facial expression and “body language”).


Early adulthood: ages 13-21:

At this stage, the young adult will have developed physical, psychological, and social awareness in relation to experiences gleaned from earlier stages of life. We are all works in progress. We take what we intuitively feel, then we take a chance via social experience, and then we process what happens. We either learn from these experiences or progress our awareness and forthrightness, or we become stuck in conceptual and social feedback loops – which can eventually “jump the fence” and progress anyways. Or not. These years are most often our first stages of sexual experience.  If touch has not been recorded in our bodies and minds as “good” at this point, there’s trouble for the person. It can be changed, in one’s psyche, but the body is a bit harder to reprogram. Patience, understanding, and a willingness to affect change within oneself are paramount. It sounds trivial and easy, but it’s not.


Mature adulthood: ages 22-? (The next boundary in age is usually “senior”, age 60-70+, but it is variable):

These are the years when body awareness, habits, and customs reach their fruition through repetition.  We are hopefully “comfortable in our own skin”, physically, psychologically, and socially.  We not only rely on the ingrained senses of self and familiar patterns of interaction with others in order to survive and mature, but we also, as parents, are in the position to set the stage for our children in the same stages we ourselves have gone through. In fact, these experiences are so ingrained, not only in action and thought; they have made their way into common parlance of everyday experiences. Consider the phrases, “Rubbing people the wrong way,” “Having a prickly or abrasive personality, or alternately, a soft touch, or magic touch,” “Someone having to be ‘handled with kid gloves,’” “Someone being touchy, or thick/thin-skinned,” “Someone being ‘out of touch’ or ‘having lost their grip.’”  Even a deeply “touching” experience is described also as “poignant (Middle English directly from Old French “poindre,” by way of Latin “pungere,” meaning to prick or touch). Metaphor for touch in language is deeply ingrained in us. Why? Because language is one of our main ways to communicate our experiences as a person.


Which also leads to the obvious: SEX and the human experience.

“Sex has been defined as, ‘the harmony of two souls and the contact of two epidermes.’ This elegantly emphasizes a basic truth: the massive involvement of the skin in sexual congress. The truth is that, in no other relationship is the skin so totally involved as in sexual intercourse. Sex, indeed, has been called the highest form of touch. In the profoundest sense, touch is the true language of sex.” [4]

  “For touch,
Touch, by the holy powers of the Gods!
Is the sense of the body; whether something makes its way in
Or when a thing, which in the body had birth,
Hurts it, or gives pleasure issuing forth
To perform the generative deeds of Venus.”
-Lucretius (c. 96 B.C-c. 53 B.C)
De Rerum Natura, II, 434

If sexual intercourse did not feel as compelling and stunningly good as it does (or can), we would have long ago become extinct.


*And in our final years, the contacts we have grown to cherish and need from ourselves and all our family and communities, in our deepest being –  physical, psychological, and social, will fade, even as the memory of its pleasures will be a secret fire in the deep recesses of the mind.

[1] Touching: The Significance of the Human Skin, Ashley Montagu, 1986

[2] Page on “Influence of a “Warm Touch” Support Enhancement Intervention Among Married Couples on Ambulatory Blood Pressure, Oxytocin, Alpha Amylase, and Cortisol”

[3] Behavioural function and neurobiological mechanisms

[4] Touching, pg.204