I Have Fibromyalgia - Why Am I Sad In Winter?
Some people, and this number may actually be larger than once supposed, do not do well in the winter. They develop a severe mood disorder that has been referred to as seasonal affective disorder. SAD may be more common in patients already suffering from fibromyalgia.
Modell and colleagues studied 226 patients with SAD and found that it actually was a syndrome consisting of multiple symptoms (Modell, JG, et al. Biol Psychiatry. 2005; 58: 658-667.) These consisted of depression, fatigue, social withdrawal, anxiety, feelings of guilt, carbohydrate craving, insomnia, increased appetite, weight gain, and gastrointestinal symptoms. The onset of these symptoms may simulate a fibromyalgia flare. And in fact, there is very little difference from a clinical viewpoint. Symptoms begin in the late fall and continue through the end of March with January and February being the worst month for symptoms.
SAD is felt to be due to abnormal functioning of the pineal gland at the base of the brain. The normal circadian rhythm is regulated by the pineal. The pineal gland secretes melatonin in the evening and shuts off melatonin during daylight hours. Dysregulation of melatonin secretion, both in the amount as well as the timing appears to be the major glitch. Srinivasan proposed that the morning fatigue- non-restorative sleep- occurring with SAD could be due to prolonged melatonin secretion in the morning (Srinivasan V, et al. J Biol Psychiatry. 2006; 7: 138-151.)
Treatments for SAD should be familiar to fibromyalgia patients. The first involves use of a light box for 30 minutes in the morning. Theoretically, this should shut off pineal secretion of melatonin because of the light exposure on the eyes. A light box has to be high intensity emitting at least 10,000 lux. A variety of these sun boxes are available. They cost approximately $400-600. The light box should be used after consulting with your medical specialist. Careful adherence to instructions will help prevent eyestrain and headaches.
Alternatively, selective serotonin reuptake inhibiting medicines (SSRIS) may also be used. The drug that has been studied the most is Prozac. While usually well tolerated, it does have potential side-effects including palpitations, sleep disturbance, and loss of libido.
Melatonin taken in a small dose (0.1 mg) in the late afternoon may also be effective for SAD. This dose is small enough not to cause drowsiness but is enough to make the pineal gland reset the bodys biological clock. Since the usual over-the-counter dose is 3 mgs, a patient may need the help of a compounding pharmacy to be able to get the tiny 0.1 mg dose.
Combining the low-dose melatonin with a light box also seems to be effective.
Exercise is another treatment that is useful. Non impact aerobic exercise helps stimulate blood flow, increases energy, and stimulates endorphin production in the brain. All of these help with the fatigue and mood problems that occur with both SAD and FM.
Finally cognitive behavioral therapy should not be neglected. It is a cornerstone of FM care and also is beneficial for SAD.
Dr. Wei (pronounced way) is a board-certified rheumatologist and Clinical Director of the nationally respected Arthritis and Osteoporosis Center of Maryland (http://www.aocm.org). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and has served as a consultant to the Arthritis Branch of the National Institutes of Health. He is a Fellow of the American College of Rheumatology and the American College of Physicians. For more information on arthritis and related conditions, go to:Fiber-myalgia
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