Q: Four years back, I was going through a period of severe stress and emotional distress because of prolonged unemployment. Around that time I had a severe pain in my shoulders, which was diagnosed as Fibromyalgia. I was given some SSRI (sertraline) and sedatives and the symptoms subsided. The pain never came back. But in subsequent years, I have had bouts of depression and fatigue. Mostly during the months from April-June, I have these lows when I suffer from fatigue, lack of concentration, no initiative for work, negative thinking etc. I had consulted a specialist in internal medicine who had re-prescribed Sertraline. He also did make me aware of the zone between depression, fibromyalgia and CFS. Although, the first few days of sertraline were marked with serious discomfort, but things subsided; I don't know whether it was because of cyclical nature or the medicine. This time I went to a top notch psychiatrist, who was glad that I could accept the facts and came to him. He prescribed fluoxetine, which I took for few months. It must be also mentioned that April-May is performance appraisal and bonus time in my organisation, and there may be a causal link as a trigger. 2004 was a little better in that I did not have to go back to any medic. But this year again there has been a career reverse. And the fatigue has come back significantly. The fact is that it manifests mostly in work place. My question is whether this syndrome is a cyclical one or is it being caused by external stress? Secondly, what should be my long term plan to tackle this? I would be very glad if you also can refer a doctor/therapist/organisation/institution which can help me in coping up with this in Mumbai provided it is not against your policy.

A:The cause of FMS (Fibro Myalgia Syndrome) remains elusive. In fact some of the symptoms often overlap those of CFS (Chronic Fatigue Syndrome) which is why most experts treat the two syndromes as the same. It is believed that there are many triggering events that precipitate its onset. These triggering events probably don't cause FMS, but rather, they may awaken an underlying physiological abnormality that is already present. Certain aggravating factors in your case could be stress, depression, anxiety, over-exertion and like you mentioned change in weather conditions (hence the cyclic nature) may all contribute to symptom flare-ups. I am not aware of your sleep pattern but with FMS often it is noticed that even if you do fall asleep easily, your brain activity remains in a state of wakefulness, which may be a cause for your chronic fatigue and may require treatment. I would recommend that you continue to visit the doctor that you were previously seeing. You could try alternate forms of treatment on his/her recommendation, such as accurses, yoga, massage therapy etc. as well as a gentle exercise program along with medication. You could also consider consulting a psychologist/psychotherapist for stress management and treatment for depression.