Fibromyalgia: Three Paradoxes of Diagnosis
Abstract
Fibromyalgia (FM) is a diagnostic construct defined by clinical criteria, lacking biomarkers
and a gold standard of reference. A non-negligible proportion of patients diagnosed with FM
actually present, either instead or in addition, other often uninvestigated conditions, most notably
small 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 and
management of FM. First paradox: positive criteria exist, but an external validator is missing. The
literature documents overdiagnosis and misdiagnosis, and successive revisions of the criteria have
redistributed the error rather than eliminating it; nonetheless, the diagnosis is often treated as
definitive and may close the door to alternative investigations. Second paradox: FM is frequently
presented to patients as incurable, yet follow-up studies and clinical testimonies report that a
variable proportion of patients improve or no longer meet the diagnostic criteria. These data are
heterogeneous and do not equate to a cure, but they do not justify a uniformly negative prognosis
and deserve to be studied rather than dismissed. Third paradox: in the absence of biological
markers, the diagnosis relies on symptomatic criteria involving cognitive, affective, and somatic
dimensions, and the ICD-11 definition is explicitly biopsychosocial; yet psychological assessment
is not considered a structural part of the diagnostic pathway. It is argued that the three paradoxes
are interconnected and that making them explicit has potential clinical, methodological, and
economic consequences. A summary table lists the main conditions that mimic FM and should
be included in the differential diagnosis. A second paper will address the interoceptive-emotional
integration model and its therapeutic implications.
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BibTeX
@misc{mahony2026fibromyalgia,
title = {{Fibromyalgia: Three Paradoxes of Diagnosis}},
author = {Alessandro Mahony},
howpublished = {Zenodo},
year = {2026},
month = oct,
doi = {10.5281/zenodo.23649789},
url = {https://zenodo.org/records/23649789},
note = {CC BY 4.0},
}
RIS
TY - UNPB
TI - Fibromyalgia: Three Paradoxes of Diagnosis
AU - Alessandro Mahony
PY - 2026
DA - 2026/10/25
PB - Zenodo
DO - 10.5281/zenodo.23649789
UR - https://zenodo.org/records/23649789
AB - Fibromyalgia (FM) is a diagnostic construct defined by clinical criteria, lacking biomarkers and a gold standard of reference. A non-negligible proportion of patients diagnosed with FM actually present, either instead or in addition, other often uninvestigated conditions, most notably small 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 and management of FM. First paradox: positive criteria exist, but an external validator is missing. The literature documents overdiagnosis and misdiagnosis, and successive revisions of the criteria have redistributed the error rather than eliminating it; nonetheless, the diagnosis is often treated as definitive and may close the door to alternative investigations. Second paradox: FM is frequently presented to patients as incurable, yet follow-up studies and clinical testimonies report that a variable proportion of patients improve or no longer meet the diagnostic criteria. These data are heterogeneous and do not equate to a cure, but they do not justify a uniformly negative prognosis and deserve to be studied rather than dismissed. Third paradox: in the absence of biological markers, the diagnosis relies on symptomatic criteria involving cognitive, affective, and somatic dimensions, and the ICD-11 definition is explicitly biopsychosocial; yet psychological assessment is not considered a structural part of the diagnostic pathway. It is argued that the three paradoxes are interconnected and that making them explicit has potential clinical, methodological, and economic consequences. A summary table lists the main conditions that mimic FM and should be included in the differential diagnosis. A second paper will address the interoceptive-emotional integration model and its therapeutic implications.
ER -