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SIGNS, SYMPTOMS, AND MECHANISMS IN FIBROMYALGIA: AN

EXPERIENCE REPORT AND REVIEW WITH A NEUROSCIENTIFIC

FOCUS

Marcelino da Silva Cavalcante1

Jaira Andrade2

Abstract: This article presents an expanded analysis of the personal report of an individual with

bromyalgia, describing signs and symptoms such as chronic widespread pain, fatigue, sensory

hypersensitivity, autonomic changes, and cognitive impairment. The report is integrated with

contemporary scientic evidence on neurobiological mechanisms, including central sensitization,

nociceptive dysfunction, neurotransmitter dysregulation, autonomic imbalance, and altered brain

connectivity. Diagnostic challenges, psychosocial implications, and multidimensional therapeutic

strategies are discussed. The text aims to contribute to the dialogue between subjective experience

and scientic evidence, reinforcing the biopsychosocial complexity of bromyalgia.

Keywords: bromyalgia; chronic pain; central sensitization; neuroscience; fatigue; quality of life.

1 Graduated in Nursing and Obstetrics, Specialist in Neuroscience, Specialist in Anthropology

of Health, Master’s student in Cultural Studies.

2 Nurse, Specialist in Higher Education Teaching

Introduction

Fibromyalgia is a syndrome characterized by diffuse musculoskeletal pain, associated with

a heterogeneous set of symptoms such as persistent fatigue, sleep disturbances, cognitive changes

(often called “brain fog”), and increased sensitivity to sensory stimuli (sensitivity to cold, light, noise,

etc.) (Brazilian Consensus on Fibromyalgia Treatment). It is estimated that about 2% of the Brazilian

population has bromyalgia, with women being the most affected group.

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Despite the growing recognition of the syndrome, diagnosis remains challenging, because

there is no specic biomarker, diagnosis is often one of exclusion and based on clinical criteria (e.g.,

the Generalized Pain Index and Symptom Severity Scale proposed by the American College of

Rheumatology). Individual response to the syndrome is heterogeneous, and many patients report

that their condition extends beyond pain, affecting daily life, mental health, and quality of life. An

important aspect for scientic advancement is the incorporation of these individual reports into

academic and clinical reection.

This work takes as its starting point the case study report of a person recently diagnosed with

bromyalgia, who constructed their account based on physical, sensory, and emotional manifestations.

From this, I organize a scientic discussion structured in four chapters: (1) contextualization of

bromyalgia and its relation to personal accounts; (2) catalog of signs and symptoms according

to reports and literature; (3) neuroscientic mechanisms involved; (4) implications for diagnosis,

management, and practical challenges. The aim is to articulate experiential voice and scientic

evidence in an integrative approach.

Signs and Symptoms: Report and Comparison with the Literature.

Report of symptoms.

In the case study report, it is possible to extract a very rich set of manifestations, including:

• Chronic generalized pain, especially in the joints, neck, and lower back; Muscle spasms;

• Edema;

• Stabbing sensations in the bones and ears; Increased sensitivity to sensory stimuli: light,

sound, cold;

• Autonomic and thermosensory symptoms: sensation of cold in the morning and at night,

altered thermal tolerance (baths with lukewarm water);

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• Feeling feverish;

• Muscle fatigue and extreme tiredness; Cognitive impairment, described as “brain fog”;

Sleep disorders (insomnia);

• Visual symptoms (eye pain, blurred vision);

• Irritability and reactivity to verbal or emotional stimuli;

• Worsening of symptoms with everyday activities (talking, eating, drinking liquids) —

“various triggers;

• Borderline psychological manifestation: report of “suicidal pain” — intense expression

of emotional suffering.

This case study report highlights the multiplicity of domains affected: sensorimotor,

cognitive, emotional, autonomic, and psychosocial.

Correlations with the scientic literature

Several clinical studies conrm that the reported symptoms are consistent with the pattern

observed in patients with bromyalgia:

Pain and sensitivityWidespread pain is the dening trait of bromyalgia, with the presence

of “tender points” and pain unrelated to any evident structural lesion. Furthermore, patients

with bromyalgia experience higher levels of pain and fatigue than patients with other chronic

musculoskeletal pain conditions.

Fatigue Chronic fatigue is a prevalent complaint, often reported as even more debilitating

than pain itself.

Cognitive impairment (“brain fog”)Problems with attention, memory, and executive function

are frequently reported by individuals with bromyalgia, even when no marked neuropsychological

decits are observed in objective tests. This is consistent with dysfunction in the central modulation

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of pain and alterations in brain processing.

Sensitivity to sensory stimuliHypersensitivity to stimuli such as light (photophobia), sound

(hyperacusis), and cold has been documented, suggesting systemic sensory amplication (not just

limited to the nociceptive system).

Autonomic and thermosensory changesReports of autonomic dysfunction are recurrent

in patients with bromyalgia, with manifestations such as orthostatic hypotension, feeling cold,

sweating, and peripheral visceral dysfunction, reinforcing a systemic component of the syndrome

(although many of these manifestations are not yet fully elucidated).

Psychosocial and emotional factorsDepression, anxiety, and other psychiatric comorbidities

are signicantly more prevalent in patients with bromyalgia, and these dimensions interact with the

perception of pain and fatigue. A study on Brazilian women demonstrated that social support acts as

a moderator of bromyalgia symptoms, indicating that interpersonal support factors can mitigate the

clinical impact of the syndrome.

Diagnostic and assessment challengesInstruments such as the Widespread Pain Index and

the Symptom Severity Scale are widely used, but there is criticism regarding their specicity for

bromyalgia versus other chronic musculoskeletal pain conditions.

Thus, the case study report aligns well with the literature, reinforcing the heterogeneity of

symptoms and the need for a multidimensional approach.

A neuroscientic approach to bromyalgia

To understand why such diverse and seemingly disconnected manifestations occur in

bromyalgia, it is necessary to revisit knowledge about chronic pain, central modulation, and neural

plasticity.

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Central sensitization and nociceptive dysfunction

One of the central concepts in contemporary models of bromyalgia is...central awareness—

the process by which neurons in the spinal cord and supramedullary pathways become more reactive

to nociceptive stimuli and, eventually, to non-nociceptive stimuli (allodynia). In this context:

The peripheral nociceptive afferent pathway may be normal or only slightly impaired.

The effect is altered, but the amplication occurs more proximally (in the spinal cord and

brain). There is a decrease in the activation thresholds of nociceptive neurons in the dorsal spinal cord,

facilitating the transmission of pain signals with weak stimuli.

Descending inhibitory pathways (e.g., involving serotonin and norepinephrine) may be

compromised, reducing the central nervous system’s (CNS) ability to effectively modulate pain.

Neurotransmitters, neuromodulation, and subclinical inammation

Several neurotransmitters and biochemical mediators are implicated in bromyalgia:

Altered levels of substances such as glutamate, substance P, and neuropeptides have been

detected in studies with patients with bromyalgia, contributing to increased central excitability.

Serotonin and norepinephrine, which are part of descending inhibitory pathways, are

frequently out of balance, justifying the use of antidepressants with serotonergic and norepinephrine

action in the management of bromyalgia pain.

Emerging hypotheses suggest that low-grade inammatory mediators (cytokines) and

oxidative stress may contribute to chronic neural sensitization, although this inammatory component

is not as well characterized as in classic autoimmune diseases.

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Neuroimaging and brain connectivity

Studies using functional neuroimaging techniques, such as fMRI (functional magnetic

resonance imaging), have provided evidence of alterations in the brain activation pattern of people

with bromyalgia. Some ndings include:

Altered connectivity between regions involved in pain processing, such as the insula, anterior

cingulate cortex, prefrontal cortex, and thalamus.

Increased activation in sensory areas and decreased inhibitory modulation in pain circuits.

Differences in effective connectivity between brain regions in patients with chronic pain,

pointing to functional reorganizations associated with the perception of continuous pain.

A recent integrative study (Adler et al., 2023) discusses ve prominent theories of bromyalgia:

central sensitization, cytokine inammation, muscle hypoxia, tender point theory, and small ber

neuropathy. The review suggests that abnormalities detected by fMRI and muscle elastography may

reect both structural and functional changes in tissue and central neural processing.

Integration: why so many different symptoms?

Based on these foundations, an integrative model can be proposed to explain multidimensional

storytelling:

Central sensitization makes peripheral and central neurons more responsive to weak stimuli,

resulting in pain from everyday stimuli (such as speech, liquid intake) - cold liquids are bad, they hurt

your teeth and gums, anything natural is better.

Dysfunction of inhibitory pathways (reduced serotonin/norepinephrine and possible

impairment of GABAergic pathways) compromises pain suppression.

Sensory modulation in other domains (vision, sound, cold) can be affected in an adjacent

manner, as sensory circuits have interconnections with pain processing systems in the CNS, leading

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to generalized hypersensitivity.

Extreme fatigue and “brain fog” can emerge from persistent cognitive overload due

to maintaining pain vigilance, extremely high demand on neural resources, and subclinical

neuroinammation.

Autonomic and thermosensory changes may reect dysfunctions of the sympathetic-

parasympathetic pathways, possibly activated by chronic stress and persistent activation of the

pituitary-adrenal axis (HPA axis).

Finally, emotional distress and psychosocial overload worsen the state of sensitization—

there is a feedback loop between pain, stress, and cognitive changes.

This neurobiopsychosocial model helps to understand why such diverse manifestations (pain,

sensory changes, fatigue, and emotional impact) coexist and reinforce each other in many patients

with bromyalgia.

Diagnostic and therapeutic implications and challenges. Challenges in diagnosis.

The heterogeneity of bromyalgia makes diagnosis difcult. Often, professionals disregard

reports that go beyond pure musculoskeletal pain. The absence of specic complementary examinations

leads to diagnostic delays and prolonged suffering.

Standardized instruments (WPI, SSS) are useful, but they do not capture the full complexity

of individual reports and may not discriminate well between bromyalgia and other chronic

musculoskeletal pain. It is also necessary for clinicians to value the patient’s subjective report and

experience, integrating clinical, phenotypic, and psychosocial indicators.

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Therapeutic approaches and multidimensional management

The Brazilian Consensus on Fibromyalgia Treatment recommends a combined approach,

associating pharmacological and non-pharmacological interventions. Some important aspects:

Pharmacotherapy: use of antidepressants (e.g., duloxetine, amitriptyline), anticonvulsants

(pregabalin), and adjuvant medications that modulate pain neurotransmitters. These drugs aim to

rebalance the central modulation of pain.

Exercise and physical activityLight to moderate intensity activities (walking, water aerobics,

stretching) have shown evidence of improving pain, fatigue, and quality of life, although adherence is

often hampered by intense sensitivity and fatigue.

PsychotherapyTechniques such as cognitive behavioral therapy, mindfulness, and cognitive

restructuring are useful for dealing with the emotional impact of chronic pain, promoting resilience,

and modulating pain perception.

Complementary therapiesApproaches such as acupuncture, transcutaneous electrical nerve

stimulation (TENS), relaxation techniques, and physiotherapy are often integrated, although results

vary among patients.

Patient education and trigger managementUnderstanding and identifying personal triggers

(such as certain foods, stress, cold, prolonged conversations), adjusting routines, and promoting self-

awareness are essential strategies for reducing pain peaks.

Psychosocial support and interpersonal supportFamily and community support networks,

support groups, and education on chronic pain can lessen the emotional impact and promote therapeutic

adherence.

Limitations, gaps, and suggestions for future research.

Even with the progress, there are still signicant challenges:

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Most studies are cross-sectional — longitudinal trials that would allow for the assessment of

causality and temporal evolution are lacking.

There is a gap in the use of reliable biomarkers or routine neuroimaging to aid in the diagnosis

and stratication of patients.

Existing therapies have moderate effectiveness and vary from patient to patient; personalized

medicine strategies are still in their infancy.

The integration of subjective patient reports with quantitative methods (questionnaires,

scales, neuroimaging) is underexplored; research using mixed methods could improve this dialogue.

Multicenter and cross-sectional studies that include affected populations (men, different age

groups, and sociocultural contexts) are needed to broaden the generalizability of the ndings.

Study Case Study: Patient Report Compared with Scientic Literature

Chapter 5 integrates the direct accounts of a patient diagnosed with bromyalgia with the

scientic data presented earlier. Each topic combines: the lived experience, correlation with the lite-

rature, and a nal analytical consideration, reinforcing how the case study complements the scientic

evidence.

Generalized chronic pain. Report:

The patient describes intense, diffuse pain involving the cervical, thoracic, lumbar, and

sacral regions, associated with a sensation of cramping without bowel movements—a visceral pain

irradiated.

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Confrontation with literature:

Studies indicate that patients with bromyalgia present with diffuse musculoskeletal pain,

but they also describevisceral and myofascial components, reinforcing the multisystemic nature of

the syndrome. The literature conrms that the pain is not limited to the muscle:There is involvement

of joints, fascia, and even poorly localized visceral perceptions., associated with central awareness.

Consideration:

The report demonstrates how bromyalgia pain goes beyond the classic notion of “muscle

pain”; it is diffuse, deep, visceral, and difcult to locate. These aspects reinforce the need for a

diagnostic approach that goes beyond the conventional musculoskeletal examination.

Bone pain, jaw pain, and tooth fragility. Report:

It describes spontaneous jaw pain, a feeling of ear blockage, pain in the dental arch, enamel

fragility, and worsening with acidic foods.

Confrontation with literature:

Temporomandibular joint involvement is frequently reported in individuals with bromyalgia,

partly due to muscle hyperactivity and central nociceptive amplication. Furthermore, the literature

describes...orofacial hypersensitivitysuggesting that craniofacial structures are affected by the same

systemic sensory dysfunction. The reported dental fragility lacks direct evidence in the literature, but

it may be...secondary phenomenona:

bruxism;

tension mandibular;

xerostomia drug-induced;

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hypersensitivity sensory experience of the enamel.

Consideration:

This report broadens the discussion on understudied craniofacial manifestations in

bromyalgia. It indicates the importance of integrating dentistry, otolaryngology, and rheumatology

in the care of these patients.

Autonomic and thermosensory symptoms. Report:

Reports feeling cold in the morning and at night, low tolerance to extreme temperatures, a

preference for lukewarm baths, and worsening of pain with cold liquids.

Confrontation with literature:

A dysfunction autonomous and widely documented in patients with bromyalgia, including:

intolerance to the cold,

instability thermal,

changes sudomotoras,

phenotypes of sensory hypersensitivity.

Worsening pain with cold liquids suggeststhermosensory allodynia, recognized in

experimental studies of central sensitization.

Consideration:

The patient’s experiences clearly illustrate the thermo-sensory amplication described in

neurobiological models of bromyalgia, reinforcing the multisystemic nature of the syndrome.

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Irritability and emotional reactivity. Report:

It refers to verbal aggression, “zero patience,” and an exacerbated emotional reaction.

Confrontation with literature:

Emotional changes are common due to:

overload chronic neuralgia;

failures in serotonergic inhibitory pathways; – cognitive fatigue;

changes prefrontal-limbic connectivity described in fMRI studies.

These conditions lead to areduction of emotional resilienceand increased reactivity to stress.

Consideration:

The report reinforces the idea that emotional expression in bromyalgia should be understood

as a neurobiological and psychosocial consequence, and not as a personality trait.

“The pain of suicide” and emotional suffering.

Account:

It describes a desire not to speak to anyone, a feeling of being misunderstood, abandonment

and contempt.

Confrontation with literature:

Fibromyalgia presents a higher prevalence of depressive symptoms and feelings of

helplessness. The concept reported as “suicidal pain” appears in qualitative studies as an extreme

expression of emotional suffering and social isolation. The literature also shows that the perception of

family or medical invalidation increases the risk of psychological distress.

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Consideration:

The account reinforces the need for psychosocial support and clinical validation, as well as

interventions that address existential suffering and not just physical pain.

Muscle and joint changes and possible dysfunctions of myelin

Report:

He mentions that the changes do not appear on MRI and refers to a sensation of muscle and

joint dysfunction, questioning possible involvement of the myelin sheath.

Confrontation with literature:

Conventional MRI rarely detects changes in bromyalgia, which reinforces the theory that

the syndrome involves...functional, not structural, dysregulation.

Although bromyalgiait is not a demyelinating diseaseThere are studies on:

neuropathy of small bers;

micro-disorganizations functional in afferent pathways;

reduction of central inhibitory modulation.

Consideration:

The account shows how the lack of visible markers in tests generates distress and a feeling

of clinical invisibility. This reinforces the importance of functional tests and empathic validation of

suffering.

Pain with everyday stimuli (talking, drinking liquids)

Report:

She reports pain triggered by talking, drinking liquids, and worsened by cold liquids.

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Confrontation with literature:

This phenomenon corresponds tomechanical allodynia(speech) andthermal allodynia (cold

liquids), both widely described in central sensitization.

Research shows that bromyalgia pain can be triggered by stimuli that do not normally

activate nociceptors.

Consideration:

This case clearly illustrates how sensory enhancement profoundly modies daily life, an

aspect that is rarely explored in traditional clinical scales.

Frustration with diagnosis and feeling of invalidation. Report:

Report frustration for the lack of exams conclusive and sensation of to be discredited.

Confrontation with literature:

Qualitative studies on patients with bromyalgia demonstrate:

sensation of stigma;

perception of “invisible pain”;

difculty in obtaining medical and family recognition.

This phenomenon has a direct impact on mental health and treatment adherence.

Consideration:

This nding highlights the need for training professionals in empathetic communication and

in recognizing the legitimacy of subjective reports in bromyalgia.

Pharmacotherapy and side effects: Report.

He mentions that medications such as duloxetine, amitriptyline, and pregabalin did not

provide relief.

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The pain caused liver overload.

Confrontation with literature:

The literature records its effectiveness.modestOf these treatments, approximately 30%

of patients experience signicant improvement. Side effects are common and lead to treatment

discontinuation.

Consideration:

The report reinforces the need for personalized therapy and alternatives that take into account

individual pharmacological limitations.

Physical exercises, complementary therapies and responses paradoxical

Report:

Exercises They brought no improvement.

Acupuncture The pain worsened even after 10 sessions.

Activities Dance, hydrotherapy, and warm water bring improvement.

Activities Those that require effort get considerably worse.

Confrontation with literature:

Although the literature suggests benets from light to moderate exercise, many patients,

especially those with strong central sensitization, report signicant worsening with physical exertion

(post-exercise phenomenon).

This is also described in overlapping syndromes, such as chronic fatigue.

Hydrotherapy in warm water shows strong evidence of improving pain and mobility.

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Consideration:

This case demonstrates that the response to exercise in bromyalgia is not uniform; it depends

on the sensitization phenotype and individual tolerance. This reinforces the need for individualized

protocols.

Final considerations (Conclusion)

The personal account analyzed offers a vivid and profound, impressive testimony to the

complexity of bromyalgia and its multiple affected domains—sensory, emotional, cognitive, and

autonomic—as well as the complexity of bromyalgia symptoms, reinforcing its multisystemic

nature. Her experience confronts and simultaneously conrms the neuroscientic models presented,

reinforcing that bromyalgia is more than a painful condition: it is a central amplication disorder that

alters the body’s relationship with the environment and with the self.

The ndings are consistent with current neuroscientic evidence, according to which

bromyalgia involves central pain amplication, sensory alterations, autonomic dysfunction, and

signicant psychosocial impact.

The coexistence of chronic pain, extreme fatigue, sensory hypersensitivity, cognitive

impairment, and emotional distress. This type of narrative reinforces the need for research and

clinical approaches not to reduce the syndrome to a single domain (e.g., musculoskeletal pain), but to

recognize its multidimensional nature.

The absence of objective markers does not diminish its clinical legitimacy; on the contrary,

it reinforces the essential role of subjective reporting and skilled listening.

Neuroscientic evidence suggests that bromyalgia can be understood as a condition

ofcentral amplication, in which the neural regulation of pain, sensitivity, and cognitive-emotional

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states is altered. Changes in pain modulation circuits, neurotransmitter imbalances, reorganizations

of brain connectivity, and possible low-grade inammatory components contribute to a feedback loop

between pain, fatigue, and stress.

For the clinic, this means that management must be multidisciplinary, combining

pharmacological interventions, physical rehabilitation, psychological support, and chronic pain

education. Assessing only pain intensity without considering sensory triggers, cognitive signals, and

the emotional context results in undertreatment or insufcient therapy.

It is considered that: the patient’s subjective experience is a valuable source of scientic

data; neurobiopsychosocial models integrate the clinical phenomenon more effectively; management

should be individualized and multidisciplinary; validation of pain and the patient’s experience is an

essential part of care.

This study reinforces the need for greater integration between research, clinical practice, and

personal accounts, contributing to a more humane and scientically accurate approach.

Finally, this work highlights the importance of valuing the patient’s voice—integrating rich

subjective accounts with scientic methods is both a challenge and an opportunity. Fibromyalgia does

not t into a single model, and clinical science needs to be open to continuous dialogue between lived

experience and theory.

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