What is the recommended evaluation and management for a 41‑year‑old woman with chronic fatigue, fibromyalgia and sleep disturbances who has been referred for a psychiatric consultation?

Management of a 41-Year-Old Woman with Fibromyalgia, Chronic Fatigue, and Sleep Disturbance

Begin with patient education about fibromyalgia as a chronic pain disorder with central sensitization, then immediately initiate a graduated exercise program as the only "strong for" therapy, and reserve pharmacotherapy specifically for severe sleep disturbance using low-dose amitriptyline 10–25 mg at bedtime as first-line. 1

Initial Psychiatric Consultation Focus

Screen for Primary Sleep Disorders

• Evaluate for obstructive sleep apnea and restless leg syndrome through clinical history, as these primary sleep disorders are common in fibromyalgia patients and require polysomnography if suspected. 2
• Ask specifically about witnessed apneas, loud snoring, daytime sleepiness (Epworth scale), and uncomfortable leg sensations at rest that improve with movement. 2

Assess for Mood Disorders and Maladaptive Coping

• Screen for major depression and anxiety disorders using validated tools (PHQ-9, GAD-7), as psychological therapies are indicated specifically for mood disorders and unhelpful coping strategies. 1
• Cognitive behavioral therapy carries Level Ia, Grade A evidence for patients with concurrent mood disorders. 3

Evaluate Sleep Hygiene and Current Sleep Patterns

• Document sleep onset latency, total sleep time, number of awakenings, and whether sleep is non-restorative. 4, 2
• Review caffeine intake, screen time before bed, bedroom environment, and sleep-wake schedule consistency. 5

Non-Pharmacological Management (First-Line, Mandatory)

Exercise: The Only "Strong For" Recommendation

• Prescribe a graduated aerobic exercise program starting at 10–15 minutes of low-intensity walking, swimming, or cycling 2–3 times weekly, increasing over 4–6 weeks to 20–30 minutes 3–5 times weekly. 1, 3
• Add resistance training targeting major muscle groups 2–3 times weekly once aerobic tolerance is established. 3
• Exercise improves pain (effect size ≈0.65), physical function (effect size ≈0.66), and promotes sleep quality. 3, 4
• Critical pitfall: Increasing intensity too rapidly triggers symptom flare-ups; prioritize duration over intensity during the first 8 weeks. 3

Cognitive Behavioral Therapy for Sleep and Mood

• Refer for CBT if screening reveals depression, anxiety, or catastrophizing pain behaviors, as CBT produces modest but durable reductions in pain (effect size ≈−0.29) and disability (effect size ≈−0.30). 3
• CBT for insomnia specifically addresses sleep-onset and sleep-maintenance difficulties. 2, 5

Adjunctive Physical Therapies

• Heated pool therapy (hydrotherapy) 2–3 times weekly for 25–90 minutes over 5–24 weeks carries Level IIa, Grade B evidence for fibromyalgia. 3
• Meditative movement therapies (yoga, tai chi, qigong) improve sleep (effect size ≈−0.61) and fatigue (effect size ≈−0.66) when practiced 1–2 hours weekly for 8–12 weeks. 3

Pharmacological Management for Sleep Disturbance (Second-Line)

When to Initiate Pharmacotherapy

• Reserve medications for patients with severe sleep disturbance who have not responded to 4–6 weeks of sleep hygiene, exercise, and CBT. 1
• The EULAR guideline explicitly states pharmacotherapy is indicated "for severe pain or sleep disturbance" only after non-pharmacological approaches. 1

First-Line Pharmacotherapy for Sleep

• Amitriptyline 10 mg at bedtime, increasing by 10 mg weekly to target 25–50 mg nightly, is the preferred agent for sleep disturbance in fibromyalgia. 3, 6, 2
• Amitriptyline improves sleep problems (effect size 0.47), reduces pain (effect size −0.40), and decreases fatigue (effect size 0.48) with Level Ia, Grade A evidence. 3
• The number needed to treat for 50% pain relief is 4.1. 6
• Amitriptyline proved superior to duloxetine and milnacipran specifically for sleep disturbances. 2
• Caution in older adults (≥65 years) due to anticholinergic effects; start at 10 mg and titrate slowly. 3

Alternative: Pregabalin for Sleep and Pain

• Pregabalin 150 mg at bedtime, titrating to 300–450 mg/day in divided doses, improves sleep and pain with Level Ia, Grade A evidence. 3, 4
• Pregabalin increases short-wave sleep and reduces alpha intrusions during non-REM sleep. 4
• Do not exceed 450 mg/day; higher doses provide no additional benefit but increase adverse events (dizziness, somnolence, weight gain). 3

Cyclobenzaprine as a Weak Alternative

• Cyclobenzaprine 5–10 mg at bedtime shows very small improvement in sleep (effect size 0.34) but carries an 85% side-effect rate and only 71% completion rate. 1
• Rated "weak for" with 75% expert agreement; use only if amitriptyline and pregabalin are contraindicated. 1

What NOT to Do

Medications to Avoid

• Never prescribe strong opioids or corticosteroids for fibromyalgia; they lack efficacy and cause significant harm. 1, 3, 6
• Do not use NSAIDs as monotherapy; they show no benefit over placebo for fibromyalgia pain. 3
• Avoid stimulant medications for fatigue; guidelines highlight lack of benefit and potential cardiovascular side effects. 3

Passive Therapies to Avoid

• Chiropractic manipulation has strong consensus (93% agreement) against use in fibromyalgia. 3
• Massage therapy has weak evidence (86% agreement against routine use); limit to 1–2 sessions weekly for up to 5 weeks only as an adjunct, never as primary therapy. 3

Treatment Algorithm

Stage 1 (Weeks 0–6)

• Provide education on fibromyalgia as a chronic pain disorder with central sensitization. 1
• Initiate graduated aerobic exercise program. 1, 3
• Implement sleep hygiene measures. 5
• Screen for and treat primary sleep disorders (OSA, RLS). 2

Stage 2 (Weeks 6–12, if <30% improvement)

• Add CBT for insomnia and/or mood disorders. 3, 2
• Consider heated pool therapy or meditative movement therapy. 3
• If sleep remains severely impaired, initiate amitriptyline 10 mg at bedtime, titrating to 25–50 mg. 3, 6, 2

Stage 3 (Week 12 reassessment)

• If amitriptyline provides inadequate sleep improvement, switch to pregabalin 150 mg at bedtime, titrating to 300–450 mg/day. 3, 4
• If partial response, continue current regimen and optimize exercise adherence. 3

Stage 4 (Severe disability or refractory symptoms)

• Consider multimodal rehabilitation program combining exercise, CBT, pharmacotherapy, and physical therapies. 1
• Reassess every 4–8 weeks using pain scores (0–10 scale, target ≥30% reduction), sleep quality measures, and functional status. 3, 6

Critical Pitfalls

• Do not start with pharmacotherapy; exercise is the only "strong for" recommendation and must be the foundation. 1
• Do not prescribe duloxetine or milnacipran primarily for sleep; these SNRIs are inferior to amitriptyline for sleep disturbance. 2
• Do not combine pregabalin with gabapentin; they bind identical targets and the combination is pharmacologically redundant. 3
• Do not rely on passive modalities (massage, manipulation); they must never replace active exercise. 3
• Do not escalate amitriptyline above 75 mg/day or pregabalin above 450 mg/day; higher doses increase adverse events without additional benefit. 1, 3

Expected Outcomes

• Effect sizes for all fibromyalgia treatments are modest (typically 0.3–0.8 standardized mean difference). 1, 3
• Sleep improvement with amitriptyline or pregabalin typically emerges within 2–4 weeks. 4, 2
• Exercise benefits accumulate gradually over 8–12 weeks. 3
• Combination of non-pharmacological and pharmacological approaches may provide greater benefit than either alone. 3, 5