Editor – We appreciate the RCP concise guideline on fibromyalgia (FMS),1 but are disappointed attention deficit hyperactivity disorder (ADHD) is not mentioned. Anxiety and depression are mentioned but these may be merely symptoms secondary to underlying disorders (eg post-traumatic stress disorder, ADHD, autism), and we risk oversimplifying the psychological part of the biopsychosocial model. Several studies show that ADHD (either formally diagnosed or implied by positive screening tests) is prevalent in patients with FMS: 44.7% in a South African study,2 24.5% in an Italian study,3 32.3% in a Spanish study,4 25% in a study undertaken in the Netherlands,5 and 29.5% in a Turkish study.6 Symptoms of ADHD correlate with severity of FMS.7 Bou Khalil et al8 suggest how the psychopathology of ADHD may predispose to FMS. Patients with suspected but unconfirmed FMS may be likely to have similar rates of ADHD.
As early as 1998, Krause et al9 noticed that some patients with ADHD had FMS and that treatment with stimulants could help both conditions. Despite the absence of randomised controlled trial evidence, it remains likely that treating comorbid ADHD improves quality of life, if not FMS directly. It is interesting to note10 that methylphenidate improves tolerability of pain in ADHD (without FMS). The RCP guidelines are aimed at generalists, who are responsible for referring to mental health services: it would be important not to miss a common treatable comorbidity. FMS may also be associated with prior PTSD11 and autism,12 which may benefit also from specific interventions.
Physicians, and commissioners, may note that ADHD is common in other ‘physical’ conditions,13 particularly chronic fatigue syndrome, and hypermobility spectrum disorders, which are also associated with FMS. Further, physicians may be interested to know that ADHD is associated with autonomic dysfunction such as postural orthostatic tachycardia syndrome (POTS), functional bowel disorders, functional urinary disorders such as enuresis, migraine, and other conditions.
Competing interests
Drs Leaver & Parry are affiliated with the UK Adult ADHD Network (UKAAN).
- © Royal College of Physicians 2023. All rights reserved.
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