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FIBROMYALGIA AND WORKERS’ COMPENSATION: INTRODUCTION . 1031 I. OVERVIEW OF FIBROMYALGIA . 1032 A. Symptoms and Problems Associated with Fibromyalgia . 1032 B. History of Fibromyalgia . 1034 C. Causes and Treatments of Fibromyalgia . 1036 II. CONTROVERSY SURROUNDING FIBROMYALGIA. 1038 A. Criticism of the Tender Points Test . 1039 B. A Purely Psychological Condition? . 1040 C. Can Physical Trauma Cause Fibromyalgia? . 1040 D. Malingering and Fibromyalgia . 1041 III. OVERVIEW OF WORKERS’ COMPENSATION . 1041 IV. PROBLEMS FOR FIBROMYALGIA PATIENTS ATTEMPTING TO RECOVER WORKERS’ COMPENSATION. 1043 A. Fibromyalgia as an Injury by Accident—Problems with B. Fibromyalgia as an “Occupational Disease” . 1045 C. The Effects of Malingering on Recovery . 1046 D. Effect of These Problems on the Ability of Fibromyalgia Patients to Recover Workers’ Compensation Benefits . 1046 V. SOLUTIONS FOR COURTS TO ALLOW FIBROMYALGIC WORKERS A FAIR Fibromyalgia is an extremely controversial medical condition.1 This controversy has also spilled over into the legal system, causing fibromyal-gia to be “the most prevalent chronic pain syndrome found in litigation today.”2 This Note seeks to examine the area of fibromyalgia in the con-text of recovery under workers’ compensation statutes. Part I of this Note addresses current medical knowledge about fibro- myalgia. Part II explains the controversy over this mysterious illness. Part III sets forth the basics of recovery under workers’ compensation law. Part Law and the Problem of Pain, 74 U. CIN. L. REV. 285, 287 (2005). 1032 Alabama
IV points out the many problems that arise when workers suffering from fibromyalgia attempt to recover workers’ compensation benefits. Finally, Part V offers possible solutions to solve these problems and allow real fibromyalgia sufferers a fair opportunity to be compensated. A. Symptoms and Problems Associated with Fibromyalgia Fibromyalgia is a chronic pain syndrome featuring widespread muscu- loskeletal pain and “generalized tender points.”3 “The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek [terms] for muscle (myo) and pain (algia).”4 Unlike arthritis, which causes pain and swelling in the joints, fibromyalgia causes pain in the soft tissues lo-cated around joints, in skin, and in organs.5 The pain is usually a wide-spread aching or burning sensation that ranges from moderate discomfort to severe, disabling pain and varies from patient-to-patient, day-to-day, and location-to-location.6 Often, the pain is described by patients as “head-to-toe.”7 It is a syndrome and not a disease.8 While a disease is linked to a specific cause or causes and identifiable signs and symptoms, a syndrome is a “collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.”9 In addition to widespread pain and tender points, fibromyalgia is often associated with a wide range of other problems. These problems most commonly include anxiety, fatigue, cognitive and memory difficulties (“fibro fog”),10 depression, irritable bladder syndrome (frequent and ur-gent urination), temperature sensitivity, paresthesias (tingling sensation), irritable bowel syndrome, and sleep disorder.11 More than one-half of fi- 3. Sangita Chakrabarty & Roger Zoorob, Fibromyalgia, 76 AM. FAM. PHYSICIAN 247, 247 (2007). 4. Nat’l Inst. of Arthritis & Musculoskeletal & Skin Diseases, Questions & Answers about Fi-bromyalgia 1 (2004), available at [hereinafter Q&A about Fibromyalgia]. 5. NAT’L FIBROMYALGIA PARTNERSHIP, INC., FIBROMYALGIA: SYMPTOMS, DIAGNOSIS, TREATMENT RESEARCH 1 (2006), available at Files/Website2005/Learn%20About%20Fibromyalgia/FM%20Overview/Monograph-English.pdf [hereinafter NAT’L FIBROMYALGIA P’SHIP, INC.]. 6. Id. 7. Id. 8. Q&A about Fibromyalgia, supra note 4, at 2. “Fibro fog” is a state common to fibromyalgia patients in which a person’s brain is not fully functioning, and thinking becomes extremely clouded, making it difficult to perform even basic func-tions. DEVIN J. STARLANYL, THE FIBROMYALGIA ADVOCATE: GETTING THE SUPPORT YOU NEED TO COPE WITH FIBROMYALGIA AND MYOFASCIAL PAIN SYNDROME 14 (1999). 11. See Chakrabarty & Zoorob, supra note 3, at 247; Q&A about Fibromyalgia, supra note 4, at Fibromyalgia and Workers' Compensation 1033
bromyalgia patients also suffer from migraine headaches.12 While depres-sion and anxiety are two common conditions found in fibromyalgia pa-tients,13 “research has repeatedly shown that fibromyalgia is not a form of depression or hypochondriasis.”14 Sleep disorders and resulting fatigue are another common condition in fibromyalgia patients.15 More than 90% of fibromyalgia patients report problems sleeping.16 Studies have revealed increased stage-one sleep (“light sleep”), decreased delta sleep (“deep sleep”), and an increase in arousals.17 Thus, even a full eight hours of sleep may often leave a fibro-myalgia patient feeling as though they have not slept at all.18 New research has also uncovered accelerated gray matter loss in the brains of fibromyalgia patients.19 A study revealed that fibromyalgia pa-tients demonstrated a yearly decrease in gray matter volume at a rate more than three times that of the control group.20 Interestingly, the fibromyalgia patients’ gray matter loss occurred mainly in regions of the brain dealing with stress and pain processing.21 The structural changes may contribute to the maintenance of pain symptoms in fibromyalgia patients.22 These struc-tural changes might also be a cause of the “fibro fog” many patients expe-rience.23 A longitudinal study is necessary to discover whether the gray matter loss is a cause or consequence of fibromyalgia.24 Research has also shown that fibromyalgia patients have significant abnormalities in the manner in which they process pain. Substance P, a chemical that aids in amplifying and transmitting pain signals to and from the brain, has been found at abnormally high levels in the spinal fluid of fibromyalgia patients.25 One study showed Substance P levels in fibro-myalgia patients that were three times higher than that of the control group.26 Fibromyalgia patients also appear to have deficient levels of sero- Chakrabarty & Zoorob, supra note 3, at 250. 13. Id. 14. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 2. 15. Chakrabarty & Zoorob, supra note 3, at 250. 16. Emma K. Guymer & Geoffrey O. Littlejohn, Fibromyalgia: Top Down or Bottom Up?, 10 APLAR J. RHEUMATOLOGY 174, 176 (2007). 17. Chakrabarty & Zoorob, supra note 3, at 250. 18. See NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 1. 19. See generally Anil Kuchinad et al., Accelerated Brain Gray Matter Loss in Fibromyalgia Patients: Premature Aging of the Brain?, 27 J. NEUROSCIENCE 4004 (2007). 20. Id. at 4006. 21. Id. 22. Id. 23. See 24. Id. 25. U.S. Food & Drug Admin., Living with Fibromyalgia, Drugs Approved to Manage Pain, CONSUMER INFO., July 17, 2008, at 2, available at 26. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 4. 1034 Alabama
tonin, which regulates the intensity of pain signals sent to the brain.27 Re-searchers from Georgetown University and the University of Michigan used MRI testing to discover that brain activity was elevated when they applied pressure to the thumbnails of fibromyalgia patients compared to the control group.28 Another study found that fibromyalgia patients take much longer to recover from pain than control groups.29 These biological responses are especially important because they differentiate fibromyalgia patients from the general population and may aid doctors and researchers in attempting to form an objective method for diagnosis, which currently does not exist.30 The lack of an objective diagnosis results in more problems for those afflicted with fibromyalgia. There are no objective laboratory tests or im-aging studies that can confirm the presence of fibromyalgia.31 Combined with the array of conditions many patients experience that may lead doc-tors in different directions, this can result in a long delay after the onset of symptoms before a proper diagnosis is made.32 Some patients are shipped from doctor to doctor for years (all the time suffering with the untreated symptoms) before being diagnosed with fibromyalgia.33 The multitude of symptoms and problems associated with fibromyalgia can produce substantial problems for sufferers. Many fibromyalgia pa-tients have difficulty functioning at work and home.34 In one study, fibro-myalgia patients ranked their quality of life as 4.8 out of 10.35 The same patients, imagining their life without fibromyalgia, scored their future quality of life without the condition as 9.2 out of 10.36 Clearly, fibromyal-gia has taken over the lives of many of its patients. Although some consider it a “fad disease,” fibromyalgia-like symp- toms have been described throughout history,37 even dating back to Bibli- 27. Id. 28. Id. at 5. 29. Id. 30. See Muhammad B. Yunus et al., Letter to the Editor, 4 J. CLINICAL RHEUMATOLOGY 289, 289 (1998). 31. Russell Rothenberg, Fibromyalgia: Documentation & Treatment, 15 FIBROMYALGIA FRONTIERS 1, 1 (2007), available at About%20Fibromyalgia/Articles/Rothenberg07.pdf. 32. See STEPHEN J. MOREWITZ, CHRONIC DISEASES AND HEALTH CARE: NEW TRENDS IN DIABETES, ARTHRITIS, OSTEOPOROSIS, FIBROMYALGIA, LOW BACK PAIN, CARDIOVASCULAR DISEASE, AND CANCER 108 (2006). 35. Id. 36. Id. 37. Karen Lee Richards, History of Fibromyalgia, June 15, 2006, But see HARRY COLLINS & TREVOR Fibromyalgia and Workers' Compensation 1035
cal times.38 It has been identified through different names including chron-ic rheumatism, myalgia, and fibrositis.39 However, it was not until the late twentieth century that fibromyalgia garnered formal recognition. The American Medical Association identified fibromyalgia as a physi- cal illness and source of disability in 1987.40 In 1990, the American Col-lege of Rheumatology (ACR) set out two criteria that must be met for a diagnosis of fibromyalgia.41 First, chronic widespread pain, defined as “pain in all four quadrants of the body and the axial skeleton,” must have been present “for at least 3 months.”42 Second, a finding of pain must ex-ist at a minimum of eleven out of eighteen tender-points sites when four kilograms of pressure (8.8 pounds) is applied.43 Although fibromyalgia is “not a diagnosis of exclusion and should be identified by its own characte-ristics,”44 no laboratory tests exist to confirm its presence.45 Therefore, a complete medical history and physical exam must be performed to rule out diseases that manifest symptoms similar to fibromyalgia and are more sus-ceptible to an objective diagnosis.46 Such diseases include systemic lupus, polymyalgia rheumatica, myositis/polymyositis, thyroid disease, rheuma-toid arthritis, and multiple sclerosis, among others.47 While its exact prevalence is not known, some estimates suggest that fibromyalgia affects between approximately three and six million Ameri-cans.48 To put this into perspective, this is more than four times as many as will develop cancer this year, and six times as many as are living with HIV.49 Other estimates put the number even higher at around ten million Americans affected by fibromyalgia.50 Fibromyalgia is also not just an American phenomenon; it affects all races worldwide at rates consistent PINCH, DR. GOLEM: HOW TO THINK ABOUT MEDICINE 118 (2005) (describing fibromyalgia as a “new disease” not appearing until the late twentieth century). 38. Job describes his physical suffering from an illness that resembles fibromyalgia: “I, too, have been assigned months of futility, long and weary nights of misery. When I go to bed, I think, “When will it be morning?” But the night drags on, and I toss till dawn . . . And now my heart is broken. Depression haunts my days. My weary nights are filled with pain as though something were relentlessly gnawing at my bones.” Richards, supra note 37 (alteration in original) (quoting Job 7:3–4; 30:16–17). 39. STARLANYL, supra note 10, at 7. 40. Id. 41. Gerhard K. M. Endresen, Fibromyalgia: A Rheumatologic Diagnosis?, 27 RHEUMATOLOGY INT’L 999, 999 (2007). 42. Id. 43. Id. 44. Chakrabarty & Zoorob, supra note 3, at 249. 45. STARLANYL, supra note 10, at 8. 46. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 3. 47. Id. 48. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 1; see also Q&A about Fibromyalgia, supra note 4, at 3. 49. Jerome Groopman, Hurting All Over, THE NEW YORKER, Nov. 13, 2000, at 78. 50. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 1. 1036 Alabama
with those found in the United States.51 Fibromyalgia affects women ten times more often than it does men.52 However, some believe that at least part of this discrepancy can be attributed to fibromyalgia being underdiag-nosed in males.53 While it mainly affects women aged twenty to fifty, fi-bromyalgia exists in all types of populations, men and women from young to old.54 C. Causes and Treatments of Fibromyalgia Fibromyalgia’s causes are unknown.55 Some experts believe it can be caused by a physically or emotionally traumatic event such as a car acci-dent or surgery.56 Some attribute it to injuries or illness.57 Others believe it is caused by viruses that alter the perception of pain.58 In some cases, fi-bromyalgia occurs spontaneously, with no apparent cause.59 Genes appear to play some role in causing fibromyalgia. It is more common in family members of fibromyalgia patients60 and one study showed 28% of children with fibromyalgic mothers developed the syndrome.61 Fibromyalgia treatments are as diverse as its symptoms and possible causes. There is no cure for fibromyalgia.62 Therefore, many patients are prescribed an array of painkillers (i.e., everything from Tylenol to Oxy-contin), anti-inflammatories, antidepressants, and benzodiazepines (i.e., Valium or Xanax), sleep aids, muscle relaxants, and a variety of other medications to treat specific comorbid conditions.63 Studies estimate that patients spend about $4,570 each year on the direct costs associated with fibromyalgia such as physicians, tests, and medication.64 On June 21, 2007, the first drug approved by the FDA specifically for treating fibromyalgia, Lyrica (pregabalin), was released. Lyrica was 51. Id.; Rothenberg, supra note 31, at 1–2. 52. Chakrabarty & Zoorob, supra note 3, at 247. 53. STARLANYL, supra note 10, at 8. 54. Chakrabarty & Zoorob, supra note 3, at 247. Q&A about Fibromyalgia, supra note 4, at 3. 56. Id. at 3–4. 57. Id. at 4. 58. U.S. Food & Drug Admin., supra note 25, at 2. Viral infections like Hepatitis C and HIV may be causally linked to fibromyalgia. See Aryeh M. Abeles et al., Narrative Review: The Pathophy-siology of Fibromyalgia, 146 ANNALS OF INTERNAL MED. 726, 731 (2007). One study confirmed blood infections in fibromyalgia patients caused by mycoplasma. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 5. The significance of these findings is not yet clear. Id. 59. Q&A about Fibromyalgia, supra note 4, at 4. Chakrabarty & Zoorob, supra note 3, at 247. Advocates for Fibromyalgia Funding, Treatment, Education and Research, Facts About FMS, (last visited June 2, 2009). 62. Robert Hardy-Pickering et al., The Use of Complementary and Alternative Therapies for Fibromyalgia, 12 PHYSICAL THERAPY REVS. 249, 250 (2007). 63. See Q&A about Fibromyalgia, supra note 4, at 7–11. 64. See Karen Oliver et al., Effects of Social Support and Education on Health Care Costs for Patients with Fibromyalgia, 28 J. RHEUMATOLOGY 2711, 2716 (2001). Fibromyalgia and Workers' Compensation 1037
shown to reduce pain and improve daily function for some patients.65 While this is a step forward in the recognition and treatment of fibromyal-gia, Lyrica does not appear to be a cure-all. Instead, a multidisciplinary approach to treatment is often utilized to combat the fact that fibromyalgia often manifests itself both physically and psychologically.66 Therefore, complementary and alternative remedies are often coupled with pharmaco-logical remedies. Fibromyalgia patients frequently attempt complementary and alterna- tive remedies such as massage, movement therapies, tender-point injec-tions, chiropractic treatments, acupuncture, magnetic therapy, yoga, and various herbs and dietary supplements.67 One study, based on a sample of 111 fibromyalgia patients, discovered that 98% of the sample had at-tempted at least one form of alternative treatment during the previous six months.68 These remedies, as with the medications, are met with varying degrees of success.69 One non-pharmacological remedy that has proven to be particularly effective is exercise.70 An exercise program involving mul-tiple dimensions such as strength, aerobic conditioning, flexibility, and balance has been shown to produce positive results, particularly in pain improvement.71 The effectiveness of fibromyalgia treatments may be scored by the fi- bromyalgia impact questionnaire (FIQ),72 which is a self-administered questionnaire consisting of questions that measure the patient’s physical and mental well-being. A high score indicates a high impact of fibromyal-gia on the patient. Researchers believe the FIQ score to be a reliable indi-cator of the health status of fibromyalgia patients.73 Fibromyalgia may be categorized as either primary or secondary.74 Primary fibromyalgia, by far the most common, is the traditional form in which no trigger may be definitively established.75 Secondary fibromyal-gia, however, is associated with an underlying disease that may be easily diagnosed.76 Some researchers have attempted to further classify primary U.S. Food and Drug Admin., supra note 25, at 1. 66. Hardy-Pickering et al., supra note 62, at 251. 67. Q&A about Fibromyalgia, supra note 4, at 11; see also Chakrabarty & Zoorob, supra note 3, at 253. 68. MOREWITZ, supra note 34, at 113. 69. Q&A about Fibromyalgia, supra note 4, at 11. Chakrabarty & Zoorob, supra note 3, at 252. J.G. McVeigh et al., Tender Point Count and Total Myalgic Score in Fibromyalgia: Changes Over a 28-Day Period, 27 RHEUMATOLOGY INT’L 1011, 1012 (2007). The FIQ may be accessed online at 73. Id. 74. W. Müller et al., The Classification of Fibromyalgia Syndrome, 27 RHEUMATOLOGY INT’L 1005, 1006 (2007). 75. Id. 76. Id. 1038 Alabama
fibromyalgia into four categories: “1. fibromyalgia with extreme sensitivi-ty to pain but no associated psychiatric conditions, 2. fibromyalgia and comorbid, pain-related depression, 3. depression with concomitant fibro-myalgia syndrome, and 4. fibromyalgia due to somatization.”77 These sub-groups may aid in developing more individualized and effective treatment programs for fibromyalgia sufferers.78 Although there is no cure or guaranteed method of treatment, fibro- myalgia is not progressive.79 It is not fatal80 and has not been shown to decrease life expectancy.81 It does not damage joints, muscles, or organs.82 While it is chronic, and therefore may last a patient’s entire life, fibro-myalgia improves in many patients with time.83 II. CONTROVERSY SURROUNDING FIBROMYALGIA The controversy over fibromyalgia is perhaps best embodied by the fact that one of the men who helped bring the term “fibromyalgia” into existence, Dr. Frederick Wolfe, now disputes his own creation. Dr. Wolfe now believes: For a moment in time, we thought we had discovered a new phys-ical disease . . . But it was the emperor’s new clothes. When we started out, in the eighties, we saw patients going from doctor to doctor with pain. We believed that by telling them they had fibro-myalgia we reduced stress and reduced medical utilization. This idea, a great, humane idea that we can interpret their distress as fibromyalgia and help them—it didn’t turn out that way. My view now is that we are creating an illness rather than curing one.84 Dr. Wolfe is not the only one with a differing view on fibromyalgia. In fact, “[h]ardly any other clinical entity is currently drawing as much criti-cism as fibromyalgia.”85 One major recipient of criticism is the diagnostic criteria set forth by the ACR.86 77. Id. 78. Id. at 1008. 79. Q&A about Fibromyalgia, supra note 4, at 12. 80. Id. 81. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 1. 82. Q&A about Fibromyalgia, supra note 4, at 12. 83. Id. 84. Groopman, supra note 49, at 89. 85. Müller et al., supra note 74, at 1005. 86. See Fibromyalgia and Workers' Compensation 1039
A. Criticism of the Tender Points Test The diagnostic criteria for fibromyalgia first set forth in 1990 are 1) at least three months of chronic widespread pain, and 2) pain at a minimum of eleven out of eighteen tender points sites when four kilograms of pres-sure (8.8 pounds) is applied.87 Critics have identified several problems with these criteria. First, the tender points requirement suggests that fibromyalgia patients experience pain only at the eighteen specified locations.88 However, stu-dies suggest that fibromyalgia patients are sensitive to pain throughout the body.89 Second, the pain associated with fibromyalgia varies from day-to-day.90 Thus, a patient might experience pain at the required eleven tender points on one day and not the next.91 Third, the diagnostic criteria focus only on pain and ignore the myriad of other symptoms associated with fibromyalgia.92 In so doing, “the criteria ‘fail to capture the essence of the FM syndrome.’”93 Fourth, the tender points examination does not diffe-rentiate between men and women.94 Pain threshold is lower in women than in men; therefore, the pressure applied during the tender points examina-tion will result in a disproportionate number of women diagnosed than men.95 Fifth, the tender points examination requires the hand of a skilled physician to apply the exact amount of pressure to the correct tender points sites.96 This process is susceptible to human error and may result in an erroneous diagnosis by a physician who either applies an incorrect amount of pressure or applies the pressure to an incorrect location.97 Final-ly, the lack of a truly objective diagnosis forces doctors to rely on self-reporting, which makes validation “difficult or impossible.”98 The limita-tions of the diagnostic criteria lead to bigger concerns for some critics: “These purely subjective criteria, which are of little help in establishing an 87. Endresen, supra note 41, at 999. 88. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 3. 89. Id. 90. Id. 91. Id. In Gleason v. Samaritan Home, 926 P.2d 1349, 1354 (Kan. 1996), Dr. Frederick Wolfe found that the claimant had eleven tender points in first visit but only one tender point in the subse-quent visit. Dr. Wolfe retracted his fibromyalgia diagnosis, and the court held that the claimant was not entitled to compensation. 92. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 4. 93. Id. (quoting L.J. Crofford & D.J. Claww, Fibromyalgia: Where Are We a Decade After the American College of Rheumatology Criteria Were Developed?, 46 ARTHRITIS & RHEUMATISM 1136, 1136–37 (2002)). 94. See Endresen, supra note 41, at 999. 95. Id. at 1000. This is consistent with findings of approximately ten times more women than men diagnosed with fibromyalgia. Id. 96. NAT’L FIBROMYALGIA P’SHIP, INC., supra note 5, at 3. 97. Id. at 4. 98. Frederick Wolfe, The Fibromyalgia Syndrome: A Consensus Report on Fibromyalgia and Disability, 23 J. RHEUMATOLOGY 534, 535 (1996). 1040 Alabama
exact diagnosis, have again and again raised doubts about the very exis-tence of fibromyalgia.”99 B. A Purely Psychological Condition? Leading practitioners and academics believe that labeling symptoms as fibromyalgia often does more harm than good.100 They believe that the symptoms of fibromyalgia are real but that they originate in the mind and not in the body.101 Dr. Arthur Barsky argues that fibromyalgia patients “become trapped in the belief that their symptoms are due to disease, with future expectations of debility and doom. This enhances their vigilance about their body, and thus the intensity of their symptoms.”102 Barsky also points out the existence of “powerful groups with vested interests in the perpetuation of [fibromyalgia], including doctors and other practitioners who run clinics, lawyers involved in disability litigation, and drug compa-nies marketing treatments of unsubstantiated benefit. This locks the patient into a closed circle of belief.”103 Some experts believe that fibromyalgia is nothing more than a person overwhelmed with psycho-social stress mani-festing that stress in what is perceived as a more socially acceptable man-ner—via physical symptoms.104 C. Can Physical Trauma Cause Fibromyalgia? Other experts, while conceding that fibromyalgia does exist, believe that “[o]verall, . . . data from the literature are insufficient to indicate whether causal relationships exist between trauma and fibromyalgia.”105 However, as with most areas of fibromyalgia, the relationship between physical trauma and fibromyalgia is disputed.106 Many studies have shown that fibromyalgia can be caused by physical trauma.107 One study found that 39% of patients suffered a physical trauma before the onset of fibro- 99. Müller et al., supra note 74, at 1005. 100. Groopman, 101. Id. 102. Id. 103. Id. at 87. 104. Karen The Courts, Expert Witnesses and Fibromyalgia, 153 CAN. MED. ASS’N J. 206, e.g., A.W. Al-Allaf et al., A Case-Control Study Examining the Role of Physical Trauma in the Onset of Fibromyalgia Syndrome, 41 RHEUMATOLOGY 450, 452 (2002); Dan Buskila et al., Increased Rates of Fibromyalgia Following Cervical Spine Injury, 40 ARTHRITIS & RHEUMATISM 446, 446 (1997); Stuart Greenfield et al., Reactive Fibromyalgia Syndrome, 35 ARTHRITIS & RHEUMATISM 678, 678 (1992). Fibromyalgia and Workers' Compensation 1041
myalgia.108 Despite new studies showing a link between physical trauma and fibromyalgia, controversy remains.109 Critics also point out that malingering is a major problem in the realm of fibromyalgia. Some critics believe that, in addition to other concerns, fibromyalgia is “further complicated by the potential influence of the availability of compensation for the syndrome. In settings where compen-sation is widely available, illnesses similar to fibromyalgia have been shown to increase in apparent prevalence . . . then to fall when compensa-tion availability declines.”110 These critics point out that the lack of an objective diagnosis makes it easier for patients to malinger effectively.111 Some liken fibromyalgia to the mysterious epidemic of forearm pain that arose in Australia in the mid-1980s.112 When courts began to require objective evidence of the condition and compensation rules became more stringent, the claims suddenly disappeared.113 However, a recent study has found that fibromyalgia is more prevalent in Amish populations than non-Amish populations.114 This counters the idea that fibromyalgia patients are motivated by financial incentives because the Amish seek no compensa-tion.115 The lack of an objective diagnosis, the possibility that it is a purely psychological illness, the possibility that physical trauma cannot cause it, and malingering all cause substantial problems for fibromyalgia sufferers in the context of workers’ compensation recovery. Before examining the interplay between these problems and those caused by the requirements of workers’ compensation laws, a brief overview of the history and current state of workers’ compensation may be helpful. III. OVERVIEW OF WORKERS’ COMPENSATION In 1884, Germany became the first country to enact a workers’ com- pensation statute.116 By the end of the nineteenth century, all the industria- 109. Moshe Tishler et al., Neck Injury and Fibromyalgia–Are They Really Associated?, 33 J. RHEUMATOLOGY 1183, 1184 (2006). 110. Wolfe, 112. See Gregory C. Gardner, Fibromyalgia Following Trauma: Psychology or Biology?, 4 CURRENT REV. OF PAIN 295, 298 (2000). 113. Id. 114. Kevin P. White, Editorial, Fibromyalgia: The Answer is Blowin’ in the Wind, 31 J. RHEUMATOLOGY 636, 638 (2004). 115. This study may also lend support to the idea that fibromyalgia can be the result of physical stimulus because the Amish are noted for their long hours of manual labor. 116. ALBERT J. MILLUS & WILLARD J. GENTILE, WORKERS’ COMPENSATION LAW AND 1042 Alabama
lized nations of Europe had passed their own statutes mandating workers’ compensation.117 Although it was clear that the system of employer liabili-ty in place in the United States at that time was in desperate need of reform, the birth of workers’ compensation law came about at a slower pace.118 Powerful defenses to the common law duties of employers made recovery for injured workers extremely difficult.119 Legislatures first re-sponded to this inequity by passing so-called Employer Liability Acts.120 However, these proved unsuccessful in allowing fair recovery for injured workers.121 Thus, during the early years of the twentieth century, many states began investigating the workers’ compensation problem.122 Mary-land enacted the first workers’ compensation statute in 1902.123 Other states then began to pass and refine increasingly sophisticated statutes deal-ing with workers’ compensation in an attempt to create a workable system that would stand up to constitutional scrutiny.124 States became more and more successful in this endeavor as time passed (most states ended up adopting specific constitutional amendments to allow for workers’ com-pensation legislation),125 and Mississippi became the final state then in the union to enact such legislation in 1949.126 Modern workers’ compensation legislation requires almost all employ- ers to carry insurance or to qualify as self-insurers.127 Its purpose is to provide guaranteed monetary benefits, including medical expenses, to dis-abled employees.128 Workers’ compensation operates on a “no fault” ba-sis.129 Therefore, benefits are provided to the employee regardless of any fault on behalf of the employee that may have contributed to the disable-ment.130 Although each state has its own, somewhat unique, version of work- ers’ compensation legislation, the basic requirements are largely the 120. Id. at 12–15. 121. See 122. Id. at 19. 123. Id. This act was very limited in scope and duration, “deal[ing] only with mining, quarrying, steam or street railroads, and the municipal construction or excavation of sewers and other physical structures.” See id. at 19–20. It was voluntary for employers to join and only applied in the case of death. Id. at 20. This act was in effect for only two years before being declared unconstitutional by a Maryland court. Id. 124. See id. at 21–32. 125. JACK B. HOOD ET AL.,WORKERS’ COMPENSATION AND EMPLOYEE PROTECTION LAWS: IN A NUTSHELL 24 (2d ed. 1990). 126. MILLUS & GENTILE, supra note 116, at 31. 127. See Fibromyalgia and Workers' Compensation 1043
same.131 The first requirement is that the disablement must be the result of an injury by accident or an occupational disease.132 An injury is “acciden-tal” within the meaning of workers’ compensation statutes when it “occurs unexpectedly and without affirmative act or design by the employee.”133 “The mere apprehension that an injury [that] did occur was likely to occur [sometime] in the future does not deprive” the injury of its accidental na-ture as long as the worker did not intend or expect that the injury would result on that particular occasion.134 Many courts interpret the term “injury by accident” liberally in favor of the injured employee.135 A worker may also recover workers’ compensation benefits if the dis- ablement is a result of an occupational disease.136 An occupational disease is “[a]ny disease . . . which is proven to be due to causes and conditions which are characteristic of and peculiar to a particular trade, occupation or employment, but excluding all ordinary diseases of life to which the gen-eral public is equally exposed outside of the employment.”137 In addition to the requirement that the worker’s disablement be the re- sult of an injury by accident or an occupational disease, the disablement must also “arise out of and be in the course of employment.”138 This re-quirement is a two-part test—the injury must arise out of employment and occur in the course of employment.139 “An injury ‘arises out of’ employ-ment if a causal connection exists between the employment and the in-jury.”140 Further, an “injury arises in the course of employment when the injury and the employment coincide as to time, place, and circums-tances.”141 IV. PROBLEMS FOR FIBROMYALGIA PATIENTS ATTEMPTING TO RECOVER The recovery requirements of workers’ compensation laws and the problems inherent in fibromyalgia itself combine to present a huge array of problems for fibromyalgia patients attempting to recover benefits. The N.Y. STATE WORKERS’ COMP. BD., EMPLOYERS’ HANDBOOK: A GUIDE TO THE WORKERS’ COMPENSATION AND THE DISABILITY BENEFITS SYSTEMS FOR THE NEW YORK STATE BUSINESS OWNER 8 (2008). 132. See, e.g., Walston v. Burlington Indus., 285 S.E.2d 822, 828 (N.C. 1982). Lannom v. Kosco, 634 N.E.2d 1097, 1100 (Ill. 1994) (emphasis omitted). L.B. Priester & Son v. McGee, 106 So. 2d 394, 397 (Miss. 1958) (emphasis added) (quoting Hardin’s Bakeries, Inc. v. Ranager, 64 So. 2d 705, 706 (Miss. 1953)). 135. See, e.g., Geist v. Martin Decker Corp., 313 So. 2d 1, 3 (La. Ct. App. 1975). 136. E.g., Buffington v. Potlatch Corp., 875 P.2d 934, 936 (Idaho 1994). 137. N.C. GEN. STAT. § 97-53(13) (2007). 138. E.g., Amoco Foam Products Co. v. Johnson, 510 S.E.2d 443, 444 (Va. 1999). 139. E.g., Meade v. Ries, 642 N.W.2d 237, 243 (Iowa 2002). 140. Id. (citing Bailey v. Batchelder, 576 N.W.2d 334, 338 (Iowa 1998)). 141. Id. at 243–44. 1044 Alabama
first of these problems occurs because fibromyalgia is difficult to classify as either an injury by accident or an occupational disease. A. Fibromyalgia as an Injury by Accident—Problems with Causation Often, fibromyalgia patients attempt to recover workers’ compensation by claiming that their fibromyalgia resulted from an accidental injury sus-tained at work. The accidental injuries that workers claim resulted in fi-bromyalgia range from falls142 and physical attacks,143 to dog bites144 and small cuts.145 Despite the counterintuitive nature of the causal link between injuries such as a dog bite or small cut to fibromyalgia, claimants almost always offer scientific evidence and expert testimony to show causation. However, workers still have a difficult time proving that the fibromyalgia “arose from” the employment because its causes are not known.146 Many studies have shown that fibromyalgia can be caused by physical trauma—even minute physical trauma like a cut or dog bite.147 However, as with most areas of fibromyalgia, the relationship between physical trauma and fibromyalgia is disputed.148 Thus, courts are often presented with conflicting evidence as to whether a physical trauma may cause fi-bromyalgia.149 In a great majority of these cases, the court will settle the conflicting evidence in favor of the employer.150 After the worker appeals, the appellate court may hold nothing but, “[d]espite the presence of con-trary medical proof, it was within [the court’s] province to resolve the conflicting evidence in favor of the employer.”151 While deferring to the findings of the lower court if reasonable is the duty of the appellate court in this situation, some courts appear less willing to defer when the lower court has allowed recovery for fibromyalgia.152 Some courts have even gone as far as to reject expert testimony that fibromyalgia was caused by 142. See, e.g., Brown v. Patriot Maint., Inc., 99 P.3d 544, 545 (Alaska 2004). 143. See, e.g., Bachman Co. v. Workmen’s Comp. Appeal Bd., 683 A.2d 1305, 1307 (Pa. e.g., Va. Elec. & Power Co. v. Brice, No. 2654-95-2, 1996 WL 205841, at *1 (Va. Ct. e.g., Carter v. Williamson Eye Ctr., 906 So. 2d 503, 505 (La. Ct. App. 2005). 146. See Q&A about Fibromyalgia, supra note 4, at 3. 147. See supra note 107. 148. See discussion supra Part II.C. 149. See, e.g., Epp v. Lauby, 715 N.W.2d 501 (Neb. 2006). 150. See discussion infra Part IV.D. 151. Gaylord v. Ichabod Crane Cent. Sch. Dist., 670 N.Y.S.2d 262, 263 (N.Y. App. Div. 1998) (noting that employer presented substantial evidence to support Board’s conclusion that fibromyalgia was not causally related to employment). 152. See, e.g., Safeway, Inc. v. Mackey, 965 P.2d 22, 29–30 (Alaska 1998) (overruling grant of benefits for fibromyalgia); Payne v. Sequatchie Valley Coal Corp., No. 01501-9610-CH-00214, 1997 WL 739526, at *3 (Tenn. Dec. 2, 1997) (same); Liberty Corr. Inst. v. Yon, 671 So. 2d 194, 197 (Fla. Dist. Ct. App. 1996) (same). Fibromyalgia and Workers' Compensation 1045
an accidental injury at work even when the employer offers no contradic-tory expert testimony.153 This same scenario of courts weighing conflicting testimony in favor of the employer also plays out when employers offer evidence that fibro-myalgia does not exist at all or is a purely psychological illness for which workers may not be compensated. Because it does not exist, or is purely psychological, employers argue that the fibromyalgia did not “arise from” the employment. These causation issues present huge problems for work-ers because a “‘[c]laimant’s subjective belief that her pain syndromes . . . must have originated in her work is entitled to little weight.’”154 Thus, courts often find any offer of proof as to causation “too speculative” to warrant recovery.155 Some courts also require objective evidence of fibromyalgia, which is of course a subjective condition that is not susceptible to objective evi-dence.156 When no objective evidence is presented, workers are denied benefits.157 Claimants attempting to offer what objective evidence is avail-able of fibromyalgia, such as the tender points test, have also been denied recovery because this evidence is “transitory” and not truly objective.158 B. Fibromyalgia as an “Occupational Disease” It is perhaps even more difficult to classify fibromyalgia as an occupa- tional disease. An occupational disease, as stated above, is “[a]ny disease . . . which is proven to be due to causes and conditions which are charac-teristic of and peculiar to a particular trade, occupation or employment, but excluding all ordinary diseases of life to which the general public is equally exposed outside of the employment.”159 When workers cannot point to a specific accidental injury that led to fibromyalgia, they often attempt to classify it as an occupational disease.160 However, courts have been reluctant to accept this theory of recovery, often holding that the 153. See, e.g., Rawls v. Coleman–Frizzell, Inc. 653 N.W.2d 247, 254 (S.D. 2002). 154. Woods v. Des Moines Pub. Sch. Dist., No. 06-1008, 2007 WL 1486107, at *2 (Iowa Ct. App. May 23, 2007) (second alteration in original) (quoting decision of the Iowa Workers’ Compensa-tion Commissioner). 155. See, e.g., Edwards v. Blue Mountain Indus., 627 So. 2d 450, 451–52 (Ala. Civ. App. 1993). e.g., Norris v. Electrolux Home Prods., Inc., No. 5:06-CV-23, 2007 WL 1041153, at *6 (W.D. Mich. Apr. 5, 2007) (holding that Board did not err in denying worker benefits when no objec-tive basis was proven as to show disablement by fibromyalgia). 157. See, e.g., Sloan v. Campbell Soup Co., No. CA96-963, 1997 WL 240996, at *1 (Ark. Ct. App. May 7, 1997). 159. E.g., N.C. GEN. STAT. § 97-53(13) (2007). 160. See, e.g., Nolan v. Univ. of Akron, No. 16584, 1994 WL 432253, at *1 (Ohio Ct. App. Aug. 1046 Alabama
risks that led to the fibromyalgia were not characteristic of and peculiar to the particular occupation.161 Workers bring fibromyalgia claims under the theory of an occupation- al disease in all sorts of circumstances. Many claim fibromyalgia as the result of repetitive motions at work.162 Some have claimed poorly venti-lated fumes led to fibromyalgia.163 Despite medical evidence showing cau-sation in these cases, courts have been extremely hesitant to classify fi-bromyalgia as an occupational disease.164 C. The Effects of Malingering on Recovery Another problem that occurs when workers attempt to recover work- ers’ compensation benefits for fibromyalgia deals with the high number of malingerers. Because there is no objective diagnosis, the problem of ma-lingering is enhanced in fibromyalgia cases. The Diagnostic and Statistical Manual of Mental Disorders describes malingering as “the intentional pro-duction of false or grossly exaggerated physical or psychological symp-toms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prose-cution, or obtaining drugs.”165 Malingerers not only take advantage of the system in a financial sense but also cast a shadow of doubt over those truly suffering. Those actually malingering166 lead courts to doubt the sincerity of fibromyalgia patients in cases even when no evidence is shown to sug-gest the claimant is faking.167 D. Effect of These Problems on the Ability of Fibromyalgia Patients to Recover Workers’ Compensation Benefits Since 2003, workers’ compensation claims in which a worker sought to recover benefits for fibromyalgia have been denied in a significant ma-jority of reported and unreported cases.168 This is in stark contrast to the e.g., James v. Perdue Farms, Inc., 586 S.E.2d 557, 560–61 (N.C. Ct. App. 2003); Nolan, 1994 WL 432253, at *1; Thetford v. Am. Mfrs. Mut. Ins. Co., No. W2003-01904-SC-WCMCV, 2005 WL 1026577, at *2 (Tenn. Workers Comp. Panel May 3, 2005). 163. See, e.g., Rakowski v. State Ins. Fund, 782 N.Y.S.2d 167, 168 (N.Y. App. Div. 2004). 165. AM. PSYCHIATRIC ASS’N, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 739 (4th ed. 1994). 166. See, e.g., Sjostrand v. N.D. Workers Comp. Bureau, 649 N.W.2d 537 (N.D. 2002) (alleged fibromyalgia sufferer caught on videotape doing various strenuous activities). 167. See, e.g., Napier v. Consol of Ky., Inc., No. 2003-SC-0853-WC, 2004 WL 2364865, at *2 (Ky. Oct. 21, 2004) (doctor “could not rule out” motive for secondary gain as cause of fibromyalgia claim); Herres v. Se. Neb. Dev., No. A-04-995, 2005 WL 1022055, at *3 (Neb. Ct. App. Apr. 26, 2005) (“[A fibromyalgia diagnosis] is also consistent with . . . secondary gain.”). 168. This figure is based on an examination of all the cases since 2003 resulting from a Westlaw search in the “allcases” database for “‘workers’ compensation’ & ‘fibromyalgia.’” Fibromyalgia and Workers' Compensation 1047
purpose of workers’ compensation statutes: to provide speedy, no-fault recovery to injured workers.169 It is also shocking considering that most courts start with the presumption that recovery should be allowed. To put this rejection rate into perspective, North Carolina statistics show that in the 1999–2000 fiscal year only 132 workers’ compensation claims out of a total of 8,087 were denied in the state.170 This equals a 98.3% approval rate and a mere 1.7% denial rate. Similarly in Wyoming, studies show that for the fiscal years 2000 and 2001, approximately 89% of the reported injuries were compensable.171 In British Columbia, Canada, workers are calling for change to their system of workers’ compensation because deni-al rates reached a ten-year high in 2006 of 8.2%.172 A majority denial rate for fibromyalgia patients is far greater than expected and shows that cur-rent treatment of fibromyalgia by the courts is an injustice that must be remedied. V. SOLUTIONS FOR COURTS TO ALLOW FIBROMYALGIC WORKERS A FAIR Adding to the array of severe problems that fibromyalgia patients must deal with as a direct result of the illness are the problems in our current system of workers’ compensation that make it extremely difficult for them to recover. In order to best deal with these problems, several steps must be taken. First, courts must acknowledge the existence of fibromyalgia as a real illness. People are suffering from fibromyalgia. Despite the contentions of those who claim that it does not exist or is purely a psychological illness, too much evidence now exists that this is in fact a real illness with real consequences. Although there is no objective diagnosis for fibromyalgia, there are many commonalities among patients that are objective and all suggest its authenticity: consistent sleep patterns, gray matter loss in re-gions of the brain dealing with stress and pain processing, genetic correla-tions, abnormally high levels of Substance P, and decreased levels of sero-tonin, among others. Courts, even if not explicitly stating that their reason It should be noted that some courts are allowing recovery for fibromyalgia. A majority denial rate of course leaves a minority of claims allowed. See, e.g., V.I. Prewett & Son, Inc. v. Brown, 896 So. 2d 564 (Ala. Civ. App. 2004); Brinson v. Finlay Bros. Printing Co., 823 A.2d 1223 (Conn. App. Ct. 2003); Watson v. Johnson Controls, Inc., 36 P.3d 323 (Kan. Ct. App. 2001); Singletary v. N.C. Baptist Hosp., 619 S.E.2d 888 (N.C. Ct. App. 2005); Judy v. Dept. of Labor & Indus., No. 23474-6-III, 2005 WL 3475804 (Wash. Ct. App. Dec. 20, 2005). 170. N.C. OFFICE OF STATE PERS., RISK CONTROL SERVS. DIV., ILLNESS/INJURY AND WORKERS’ COMPENSATION STATISTICAL ANALYSIS 1 (2001), available at frames/divisions/rcs/00fiscal/Statisti.pdf. 171. WYO. LEGISLATIVE SERV. OFFICE, WORKERS’ COMPENSATION CLAIMS PROCESSING 5 (2003), available at 172. Travis Lupick, WorkSafeBC Under Fire from MLA, Others (Nov. 8, 2007), 1048 Alabama
for not allowing recovery is because they do not believe it exists, appear to have a negative perception of fibromyalgia that leads them to the con-clusion that recovery should not be allowed. When weighing equal evi-dence on both sides, courts end up ruling against recovery in the majority of cases. Educating the courts about the latest advances in fibromyalgia studies will help to rid the courts of this negative perception and allow workers a fair chance at recovery. Weeding out malingerers will also help to change the negative perception associated with fibromyalgia. Courts must find a better way to determine whether a particular plain- tiff actually has fibromyalgia or is simply taking advantage of the system. The Seventh Eighth Circuits, in ERISA claims, have recently recognized the tender points test as constituting objective evidence of the presence of fibromyalgia.173 However, this test is not without limitations of its own174 and until a truly objective test is discovered, courts should consider ac-cepting expert testimony from mental health professionals to help aid in determining whether a patient is actually suffering. Parties to workers’ compensation disputes are increasingly utilizing psychologists to evaluate the claims.175 This is especially appropriate in the fibromyalgia context where medical doctors cannot objectively determine a true diagnosis. Mental health professionals may be able to do so. One of the most commonly used and most effective tests in detecting malingering is the Minnesota Multiphasic Personality Inventory (MMPI).176 The MMPI-2 is the latest version of this test and includes the Fake Bad Scale (FBS), which is specifically designed to detect malingering in personal injury cases.177 Studies have shown the FBS to correctly classify 96% of personal injury claimants diagnosed as malingerers.178 These tests may go a long way in helping to eliminate those faking fibromyalgia and therefore lend more credibility to those actually suffering. Courts must also find an appropriate way to deal with classifying fi- bromyalgia as an injury by accident. Although many cases have cited to the fact that scientific studies are inconclusive as to whether a physical trauma may cause fibromyalgia, recent studies show that this relationship does in fact exist in some patients.179 Thus, courts should not only allow workers to offer expert testimony that the physical trauma in question did 173. Chronister v. Baptist Health, 442 F.3d 648, 656 (8th Cir. 2006); Hawkins v. First Union
Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir. 2003).
174. See
Myling Sumanti et al., Noncredible Psychiatric and Cognitive Symptoms in a Workers’ Com- pensation “Stress” Claim Sample, 20 CLINICAL NEUROPSYCHOLOGIST 754, 754 (2006). 176. John E. Meyers et al., A Validity Index for the MMPI-2, 17 ARCHIVES CLINICAL NEUROPSYCHOLOGY 157, 157 (2002). 177. Id. at 158. 178. Id. 179. See supra note 107. Fibromyalgia and Workers' Compensation 1049
cause the fibromyalgia but should also not simply rule against the worker when the employer offers conflicting expert testimony. In cases where fibromyalgia is the result of employment, but not an accidental injury, courts have limited options for recourse. However, leg-islatures can get involved to pass legislation recognizing fibromyalgia as an occupational disease. Many states have incorporated specific findings into their workers’ compensation statutes to specifically allow certain con-ditions to be considered occupational diseases. For example, North Caro-lina has made statutory allowances for twenty-eight separate conditions.180 Exceptions for specific conditions have even been made on the federal level. The Black Lung Benefits Act was first passed in 1969 and extended in 1972 to provide cash benefits for coal miners disabled by black lung disease.181 While hesitant to disrupt state systems of workers’ compensa-tion by passing the Act into law, President Richard Nixon noted that he felt compelled to do so because “States have not yet improved their own-er-financed laws to meet the challenge posed by black lung—and there are too many victims of this dread disease [to] not to have acted.”182 Perhaps current legislatures will feel so compelled to do something about the grow-ing number of fibromyalgia sufferers who are not able to fairly recover under the current system. Almost every illness has been unknown at some point in time. Even current diseases as prevalent and universally accepted as Alzheimer’s dis-
ease have eluded all attempts to find a cause, objective diagnosis, or cure.
Lesser known diseases like relapsing-remitting multiple sclerosis can also
provide a model by which fibromyalgia may be compared. Before the ad-
vent of MRI and other technologies, relapsing-remitting multiple sclerosis
sufferers were “dismissed as being psychologically disturbed or malinger-
ers, complaining of odd neurological symptoms like blindness and dizzi-
ness and drunken gait, yet appear[ing] virtually neurologically intact on
examination.”183 When the proper technology came along, however, these
patients were shown as true sufferers of a true illness.184 In the fibromyal-
gia context, just as it did with this form of multiple sclerosis,
[t]echnology ultimately will catch up with reality and will prove [fibro-
181. See Pub. L. No. 92-303, 86 Stat. 153 (1972) (codified as amended at 30 U.S.C. § 901 (2000)); Pub. L. No. 91-173, 83 Stat. 792 (1969). 182. Richard Nixon, Statement About Signing the Black Lung Benefits Act of 1972 (May 20, 1972). 183. White, 1050 Alabama
myalgia] doubters wrong.”185 Until that time, courts and legislatures must find a way to allow fibromyalgia sufferers a fair chance at recovery under workers’ compensation.



A Comprehensive Model for Behavioral Treatment of Trichotillomania Charles S. Mansueto, Behavior Therapy Center of Greater Washington and Bowie State University Ruth Goldfinger Golomb, Behavior Therapy Center of Greater Washington Amanda McCombs Thomas and Ruth M. Townsley Stemberger, Loyola College in Maryland Reprinted by permission of Association for the Advancement of Behavior Therapy Co


Köllensperger M, Geser F, Seppi K, Stampfer-Kountchev M, et al. Red flags for multiple system atrophy. Mov Disord. 2008 Jun 15;23(8):1093-9. Abele M, Minnerop M, Urbach H, Specht K, Klockgether T. Sporadic adult onset ataxia of unknown etiology : a clinical, electrophysiological and imaging study. J Neurol. 2007 Oct;254(10):1384-9. Weyer A, Abele M, Schmitz-Hübsch T, Schoch B, Frings M, Ti

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