Fibromyalgia: Three Paradoxes of Diagnosis
Year: 2026
Type: preprint
Abstract: Fibromyalgia (FM) is a diagnostic construct defined by clinical criteria, lacking biomarkersand a gold standard of reference. A non-negligible proportion of patients diagnosed with FMactually present, either instead or in addition, other often uninvestigated conditions, most notablysmall fiber neuropathy (SFN). This article does not propose a new etiopathogenetic theory;rather, it makes explicit three logical and clinical paradoxes that run through the diagnosis andmanagement of FM. First paradox: positive criteria exist, but an external validator is missing. Theliterature documents overdiagnosis and misdiagnosis, and successive revisions of the criteria haveredistributed the error rather than eliminating it; nonetheless, the diagnosis is often treated asdefinitive and may close the door to alternative investigations. Second paradox: FM is frequentlypresented to patients as incurable, yet follow-up studies and clinical testimonies report that avariable proportion of patients improve or no longer meet the diagnostic criteria. These data areheterogeneous and do not equate to a cure, but they do not justify a uniformly negative prognosisand deserve to be studied rather than dismissed. Third paradox: in the absence of biologicalmarkers, the diagnosis relies on symptomatic criteria involving cognitive, affective, and somaticdimensions, and the ICD-11 definition is explicitly biopsychosocial; yet psychological assessmentis not considered a structural part of the diagnostic pathway. It is argued that the three paradoxesare interconnected and that making them explicit has potential clinical, methodological, andeconomic consequences. A summary table lists the main conditions that mimic FM and shouldbe included in the differential diagnosis. A second paper will address the interoceptive-emotionalintegration model and its therapeutic implications.
Author: Alessandro Mahony
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7223561939