Are Psychological Treatments Effective for ... - Springer Link

Are Psychological Treatments Effective for Fibromyalgia Pain? Kati Thieme, PhD, and Richard H. Gracely, PhD

Corresponding author Kati Thieme, PhD Center for Neurosensory Disorders, University of North Carolina, CB#7280, 3330 Thurston Building, Chapel Hill, NC 27599, USA. E-mail: [email protected] Current Rheumatology Reports 2009, 11:443–450 Current Medicine Group LLC ISSN 1523-3774 Copyright © 2009 by Current Medicine Group LLC

This article considers four broad classes of psychological techniques and their effects on fibromyalgia (FM) pain. A literature search identified 14 randomized controlled trials (RCTs) of cognitive-behavioral therapy (CBT) and operant-behavioral therapy (OBT), five relaxation RCTs, five biofeedback RCTs, five hypnotherapy RCTs, and two writing intervention RCTs. For psychoanalytic therapy in FM, no RCTs have been published. The highest effect sizes (r = 0.53–2.14) for pain reduction are found after CBT and OBT group treatments. Relaxation as a single treatment has not been proven useful. Hypnotherapy and writing intervention have demonstrated mild treatment effects, whereas psychological treatment is effective in FM pain. Considering the heterogeneity of FM, the promising effects of matched interventions such as CBT and OBT with pharmacotherapy, exercise, and other treatment domains require further research.

Introduction Fibromyalgia (FM) is a chronic pain disorder characterized by the distribution of widespread pain. The 1990 American College of Rheumatology (ACR) diagnostic research criteria require pain in all four major quadrants of the body and the axial skeleton, in addition to demonstrable tenderness evoked by 4 kg of manual thumb pressure at 11 of 18 defi ned “tender points.” FM is most prevalent in women of childbearing age [1]. The primary symptom of pain is often accompanied by fatigue, decreased function, unrefreshing sleep, and comorbidities such as chronic fatigue syndrome, multiple chemical tenderness, and irritable bowel syndrome. FM is difficult to treat and the underlying mechanisms are essentially unknown. Treatment approaches for FM mostly rely on pharmacologic approaches, especially with tricyclic antidepressants

and more recently anticonvulsants (pregabalin) and serotonin-norepinephrine reuptake inhibitors (duloxetine, milnacipran) that have been approved in the United States and Europe or have sought approval for the treatment of FM. A meta-analysis of nine studies on the efficacy of tricyclic antidepressant medication showed the most significant effect on quality of sleep, little therapeutic effect on stiffness, and the least effect for sensitivity to pressure. Thirty percent of patients were responders (> 50% improvement of symptoms) [2], and recent studies have demonstrated a similar responder rate of 30% to 50% for serotonin receptor antagonists [3,4]. The modest effects of pharmacotherapy delivered in isolation have led to treatment approaches including several nonpharmacologic factors. Nonpharmacologic treatments bolster the limited efficacy of pharmacotherapy and are particularly suited for FM treatment based on evidence of the significance of psychological factors in FM development and maintenance. Besides pain, fatigue, and stiffness [5], one of the six most frequently cited exacerbating factors involved some form of emotional distress in 83% of responding patients. Additional factors included weather changes (80%), sleep disorders (79%), strenuous activity (70%), mental stress (68%), and worrying (60%) [6•]. Chronic stress (41.9%) and emotional trauma (31.3%) were also identified as triggering events. Female gender, psychological vulnerability to stress, and a stressful, often frightening environment and culture are important antecedents of FM [7]. Depression and anxiety are frequent comorbid factors in FM [8,9] associated with changes in pain perception and central hyperexcitability [10], possibly mediated by inhibited serotonergic function consistent with a mediating mechanism of central disinhibition [11]. Growing evidence supports the hypothesis of augmented pain processing in FM patients that is initiated and maintained by the interactions of sensory, affective, cognitive, and behavioral factors [12]. The presence of mechanisms that likely respond to nonpharmacologic approaches and the modest efficacy of conventional and more recent pharmacotherapies suggest a need for concomitant psychotherapeutic treatment methods designed to reduce pain-reinforcing cognition and behavior. This review considers four broad classes of psychotherapeutic techniques that have been unevenly applied to FM. For example, an internet survey of 2596 patients found that

444

I

Rheumatic Manifestations of Other Diseases

86% of responding patients endorsed resting and 47% endorsed relaxation, whereas only 8% used cognitivebehavioral therapy (CBT) [6•]. Consideration of these methods may support their use as important adjuncts to pharmacotherapy and identify optimized approaches within these categories of nonpharmacologic treatments.

Effects of CBT and OBT for Pain CBT CBT for pain usually involves various therapeutic procedures, with a focus on changing negative emotions that result from dysfunctional thinking [13••]. Two main therapeutic techniques are used in CBT: the fi rst identifies and modifies dysfunctional thought patterns that interfere with therapeutic progress. The second engages the patient in behavioral interventions aimed at breaking the vicious circle between pain symptoms and patterns of dysfunctional performance. The emphasis of cognitive-behavioral pain treatment is to replace maladaptive cognitive behaviors such as catastrophizing with positive coping strategies, such as adaptive coping. This is achieved by altering pain triggers, pain-maintaining cognitions (eg, catastrophizing), and emotions such as anxiety, helplessness, and depression. The modification of pain- relevant beliefs is achieved by cognitive strategies, cognitive restructuring [14], problem-solving training [15], and by the acquisition of new strategies of pain coping, such as relaxation, distraction from pain, imagery, and stress-reduction techniques [16]. This approach also provides an experience of the ability to interfere with the perception of pain and boosting self-efficacy expectations. CBT intends to reduce the emotions of affective distress and depression [17] and increase self-efficacy [18] and physical functioning [19], and develop improved coping strategies [20,21] to reduce pain perception and pain-related interference [22,23•].

OBT Based on general assumptions of the operant pain model, operant-behavioral therapy (OBT) for pain assumes that pain, originally considered a reflex, is maintained through reinforcement controlled by operant conditioning formulated by Fordyce [24]. He suggested a paradigm shift by expanding the concept of pain from biological processes to also include the influence of “social/contextual factors that might be little (if at all) related to neurophysiological parameters.” Pain behaviors are overt expressions of pain, distress, and suffering, such as slowed movement, bracing, limping, and grimacing [25,26]. Pain behaviors have a communicative function [26,27] and signal the presence of pain to others. A central feature of pain behaviors is that they are observable and therefore capable of eliciting a response from significant others. From an operant conditioning perspective, increased pain behaviors result from reinforcing responses by significant others. For example, solicitous responses by significant others are positively associated

with higher ratings of pain severity, more pain behaviors, greater disability, and decreased activity levels [28,29]. Pain behaviors arise through both positive (eg, excessive solicitous spouse response to pain) and negative reinforcement (eg, avoidance of unpleasant activities, catastrophizing) subconscious behavior. Pain behaviors correlate with an amplifi ed perception of pain intensity that provokes neurophysiologic changes influencing the development and maintenance of pain memory [30]. Operant learning has been shown to reduce problematic symptoms and behaviors ranging from mental problems, such as anxiety and mood disorders [9], to physical problems associated with medication misuse [31], defi cient activity levels [32], excessive use of doctor visits [33], avoidance behaviors [34], and amplifi ed pain perception in FM patients with dysfunctional psychosocial adaptation [31,35]. The aims of OBT are to both reduce pain behaviors and train healthy and assertive pain-incompatible behaviors. To achieve these aims, a number of operant learning strategies are used, such as the contingent positive reinforcement of pain-incompatible behavior and reduced or absent positive reinforcement of pain behaviors, time-contingent intake, and reduction of medication, increased bodily activity, reduction of interference of pain with activities, reduction of pain behaviors, and training in assertive pain-incompatible behaviors. Active participation of spouses is necessary because they will learn to reinforce healthy, pain-incompatible behaviors. The reduction of pain behaviors postulates the insight of both patient and spouse to distinguish between subconscious unhealthy pain behaviors and conscious healthy behaviors. One method uses red cards and green cards. A patient receives the red card when he shows pain behaviors or a green card when displaying healthy behaviors. This simple procedure is a highly effective method for patient–spouse interaction. Although a treatment in its own right, physical exercise is an essential part of an operant learning program for training of motor perception, increasing personal physical activities, and reducing avoidance behavior, intake of medication, and excessive solicitous spouse behavior [33].

RCTs integrating CBT and OBT Two current systematic reviews analyzed seven [13••] and six [36••] randomized controlled trials (RCTs) integrating CBT and OBT. Three studies were common to both reviews: Nicassio et al. [34], Vlaeyen et al. [20], and Williams et al. [19]. The review from Bennett and Nelson [13••] included studies from Bennett et al. [22], Burckhardt et al. [18], Kashikar-Zuck et al. [21], and Redondo et al. [37], whereas the review from van Koulil et al. [36••] analyzed studies by Keel et al. [38], Thieme et al. [33], and Wigers et al. [39]. Since the publication of the reviews, two further RCTs have been performed: Garcia et al. [40] and Thieme et al. [23•]. Our analysis included 14 RCTs (Table 1). The

Are Psychological Treatments Effective for FM Pain?

I

Thieme and Gracely

I

445

Table 1. RCTs of CBT and OBT for fibromyalgia-related pain

Study

Sessions, n MeasureEffect size* (treatment Follow-up, ment of pain of changes in hours) mo intensity chronic pain

Intervention in the treatment group

Intervention in the control group

No effects De Voodg et al. [42]

10 (10)

–

VAS

0

Psychomotor therapy Nontreatment group and marital counsel(n = 50) ing (n = 50)

Nicassio et al. [34]

10 (10)

6

MPQ

0

Vlaeyen et al. [20]

12 (12); 12 (12)

12

MPQ

–0.25; 0

Williams et al. [19]

4 (6)

12

MPQ

0

Standard medical treatment combined with 6 CBT sessions (n = 76)

Standard medical treatment with pharmacotherapy and aerobic exercises (n = 69)

Redondo et al. [37]

8 (20)

6

FIQ

0.42 (previous: 0.4)

CBT (n = 21)

Physical exercises

Soares and Grossi [41]

10 (20)

6

MPQ

0.07 (previous: 0.3)

Behavioral (n = 18); Waiting list (n = 17) educational (n = 18)

Wigers et al. [39]

14 (14)

48

VAS

0.1 (previous: 0.4)

Stress management (n = 20); aerobic exercises (n = 20)

Treatment as usual (n = 20)

CBT

Educational

Cognitive-educational Waiting list (n = 45) (n = 44); educational (n = 44)

Without any stable effects

Clinically significant changes of pain intensity Bennett et al. [22]

24 (36)

24

FIQ

0.9

CBT (n = 104)

Waiting list (n = 29)

Burckhardt et al. [18]

6 (12)

1.5

FIQ

1.1

Self-management with education (n = 33); education with physical exercise (n = 33)

Physical training (n = 33)

Garcia et al. [40]

9 (18)

3

FIQ

1.87

Kashikar-Zuck et al. [21]

8 (16)

16

VAS

0.81

Coping skill training (n = 15)

Self-monitoring (n = 15)

Keel et al. [38]

15 (30)

3

VAS

0.53

CBT (n = 14)

Autogenic training (n = 13)

Thieme et al. [33]

25 (75)

15

MPI

2.14†

OBT (n = 40)

Amitriptyline and physiotherapy (relaxation; n = 21)

Thieme et al. [23•]

12 (24); 12 (24)

12; 12

MPI; MPI

1.14; 1.10

CBT (n = 42); OBT (n = 43)

Social discussion as attention placebo (n = 40)

Pharmacotherapy No treatment (n = 7) (cyclobenzaprine; n = 7); CBT (n = 7); CBT + pharmacotherapy (n = 7)

*Inpatient setting. † Effect sizes for treatment groups were computed based on the formula CG (mean T2–4) – CBT/OTG (mean T2–4)/CBT/OTG (SD T1). CBT—cognitive-behavioral therapy; FIQ—Fibromyalgia Impact Questionnaire; MPI—Multidimensional Pain Inventory; MPQ—McGill Pain Questionnaire; OBT—operant-behavioral therapy; RCTs—randomized controlled trials; VAS—visual analogue scale.

sample sizes of the RCTs ranged from 30 to 164 patients. Except for the inpatient study by Thieme et al. [33], each of the studies was performed in an outpatient setting. The treatment of all studies was performed as a group treatment. There are no uncontrolled or controlled studies of CBT as individual treatment. The duration of the

treatment varied between 6 and 15 weeks, and the number of outpatient treatment hours varied from 6 to 30 hours. The inpatient study delivered 75 treatment hours in 5 weeks [33]. Although psychotherapy is not directed at reducing pain perception, 10 of 14 CBT and OBT studies showed

446

I


improvements in outcome measures of pain intensity, disability, and mood, and were clearly superior to control groups. Seven studies (50%) reported positive stable treatment effects maintained for 6 months.

Jacobson relaxation training (JRT) should be highly effective for pain reduction in FM. However, to date, no RCTs have confi rmed this assumption.

Autogenic training Clinical significance Seven studies showed treatment effects with clinical significance quantified as at least 50% pain reduction 6 to 24 months after CBT and OBT, with 42% to 65% of patients satisfying these criteria [18,21,22,23•,33,38,40]. Three studies could not find stable effects after CBT [37,39,41], and no effects were reported by four studies [19,20,34,42].

Predictors of treatment Variability in the effects of CBT and OBT clinical trials could be explained by the inclusion of patients who are unable to profit from a particular type of treatment. To address this issue for research and clinical practice, several studies have developed indication criteria for the different treatment methods. For example, clinical efficacy of CBT has been predicted by affective distress, reduced adaptive coping, less catastrophizing, low solicitous behavior, and low pain behaviors [17,43••]. Additional predictors of efficacy include cognition and coping resources [17] and duration of the disorders [38,44]. In contrast to CBT predictors, patients with clinically significant improvement of physical impairment after OBT had more pain behaviors, physical impairment, physician visits, solicitous spouse behaviors, and level of catastrophizing [43••]. Responders with clinically significant improvement of pain to CBT or OBT had lower pretreatment physical impairment in accordance with Williams et al. [19]. Patients with extremely high levels of physical impairment and pain behaviors or patients with low pain perception have a high risk for deterioration after psychological treatment [43••]. Although increased efficacy was associated with a greater number of treatment hours, the studies of these promising treatments do not give any fi ndings about the optimal intensity and duration of CBT and OBT programs.

A Swiss RCT that treated 27 FM patients with 15 treatment hours showed that CBT was superior to AT in reduction of pain intensity and psychological variables [38]. An Italian RCT involving 53 patients with FM observed higher sleep quality and lower morning stiffness after treatment with Erickson’s hypnotic analogical technique (n = 26) using individualized numbers of treatment sessions (range, 2–5) compared with an AT group (n = 27) receiving only two group sessions and daily exercises for 6 weeks [45].

Jacobson relaxation training An Austrian RCT treated 13 FM patients with four JRT (n = 13) sessions and two weekly exercises, comparing the effects to those from hydrogalvanic bath therapy (n = 12) [46]. The trial did not fi nd a significant reduction in pain, or a change in psychological symptoms, sleep quality, or pain behavior after JRT. An RCT in the United States with 24 patients randomly assigned to massage therapy or relaxation therapy group (JRT) receiving 30-minute treatments twice weekly for 5 weeks reported lower pain ratings, fewer tender points rated by physicians, decreased substance P levels, and improved sleep quality in the massage therapy group compared with the JRT group. Follow-ups were not assessed [47]. Hammond and Freeman [48] compared relaxation therapy that included different relaxation methods and breath techniques with a community patient education–exercise program using a cognitive-behavioral approach of 10 treatment hours for 10 weeks. The relaxation treatment did not result in any significant differences in pain, self-efficacy, or FM impact score after 4 and 8 months after treatment compared with the education group that achieved shortterm effects that were not sustained.

Biofeedback Cost reduction A study of the reduction of health costs after CBT/OBT found an annual reduction of $3933 per patient for hospitalization costs and an annual reduction of $1840 per patient for primary care costs. In contrast, doctor visits increased after standardized medical program by 32.2% and days of inpatient hospitalization increased by 80.2%. The standardized medical program showed a significant annual increase of $1905.50 per patient in hospitalization costs and an annual increase of $442 per patient regarding primary care costs [33].

Effects of Relaxation It is reasonable to assume that the frequent use of relaxation methods such as autogenic training (AT) and

A small electromyograph biofeedback (EMG-BFB) study compared a true EMG-BFB with a false EMG-BFB [49]. True EMG-BFB (n = 6) resulted in improvements in pain intensity, morning stiffness, and tender-point score after 5 months of treatment compared with false EMG-BFB (n = 6). A larger US RCT with 119 patients compared 1) relaxation therapy for 3 months consisting of 1 hour per month; 2) BFB as a single treatment; 3) BFB combined with relaxation for 6 weeks consisting of 1.5 to 3 hours per week; and 4) the effects of educational and attention as a control therapy. Researchers reported for all three treatment groups the improvement of self-efficacy and physical activity, but no reduction of pain intensity after the treatment. The 2-year follow-up showed positive effects for sleep and depression but not for pain reduction after all treatment groups. The combination of relaxation and


BFB led to better results than the single BFB immediately after the treatment and at the 1- and 2-year follow-ups. In particular, the improvement of physical activity 2 years after treatment was achieved only by the combination of relaxation and BFB [50]. A Dutch BFB RCT with 143 patients treated by fitness training or BFB for 24 weeks, consisting of two 30-minute sessions per week, reported neither a reduction of pain intensity nor of affective distress after each of the different treatment methods compared with a usual care control group [51]. The authors concluded that fitness training (ie, low impact) and biofeedback training had no clear beneficial effects on objective or subjective outcomes in patients with FM. Another US RCT with 64 patients used electroencephalogram neurobiofeedback treatment in 22 sessions over 11 weeks. In comparison to sham FM therapy, the actual treatment did not show any efficacy regarding pain intensity, tenderness, or affective distress [52]. In contrast to the reported four BFB studies, an Austrian RCT treating 24 patients with EMG-BFB for 12 sessions twice weekly found lower pressure-point sensitivity immediately and 3 months after the BFB treatment and improved vitality and mental health in patients 3 months after treatment without psychological comorbidity. Patients with depression showed improvement in clinical symptoms, sensory and affective pain components, and quality of life compared with the outcomes of a wait-period control group after 6 weeks. Long-term improvement was reported only in pressure-point sensitivity and magnitude of pain intensity [53]. AT and JRT do not demonstrate pain reduction, and the BFB results are inconsistent. A single therapy with AT, JRT, or BFB is not recommended according to the American Pain Society (APS) and Association of the Scientific Medical Societies in Germany (AWMF) guidelines for FM treatment.

Hypnotherapy Consistent results were found in two studies with hypnotherapy and three studies with guided imagery.

I

Thieme and Gracely

I

447

found reduced pain intensity and anxiety after guided imagery and after patient education, whereas the free talk procedure did not alter symptoms. The therapist-led free talk therapy was consequentially not beneficial for reducing pain and anxiety for these patients with FM, although the patients expressed relief while talking [55]. Fors et al. [56] published a further Dutch RCT with 55 patients treated with either guided pleasant imagery (n = 17) or guided attention imagery upon the “active workings of the internal pain control systems” (n = 22) compared with a control group “treated as usual” (n = 17) and randomly assigned to receive 50 mg/d of amitriptyline or placebo. Compared with the control group, pain diary ratings for a 4-week period declined significantly after treatment in the pleasant imagery, but not in the attention imagery group. Pleasant imagery was an effective intervention in reducing FM pain during the 28-day study period. Amitriptyline had no significant advantage over placebo during the study period. In an additional study of guided imagery, Menzies et al. [57] used a daily recording for 6 weeks in a US RCT with 48 patients. The results showed an improvement of health-related life quality and a reduction of psychological symptoms, yet no reduction of pain intensity compared with standard medical therapy. With the exception of Haanen et al. [54], the significance of the results is limited by small sample sizes and lack of follow-up evaluations. These studies did not provide information about optimal dose, use of appropriate method (eg, life hypnosis vs ablation hypnosis), comparisons with CBT, or predictors for treatment success. There are no studies of cost effectiveness. The effects of hypnotherapy and guided imagery on the symptoms of pain intensity, sleep quality, and fatigue show superiority over standard medical therapy and especially physical therapy. The APS and AWMF guidelines for diagnostics and therapy in FM recommend the treatment of patients with hypnotherapy and guided imagery in addition to highly effective treatment methods such as CBT/OBT, amitriptyline, and cardiovascular exercises.

Hypnosis

Writing Intervention

In a Dutch RCT, 40 patients with FM received hypnotherapy via a recording in eight 1-hour sessions for 3 months. The hypnotic intervention, which included sensory and affective approaches to pain control, showed significant reductions of pain intensity and fatigue on awakening and improved sleep pattern and global assessment at 12 and 24 weeks after the treatment compared with massage [54]. As noted above, an Italian RCT with 53 patients achieved improved sleep quality and improved morning stiffness without any pain reduction using Erickson’s analogical technique compared with AT [45].

A US RCT with 92 patients with FM found that written expression of traumatic experiences (20 min, 3 d) achieved a reduction of pain intensity (r = 0.49), fatigue (r = 0.62), and affective distress (r = 0.62) compared with neutral writing and therapy as usual. These positive results were maintained after 4 but not after 10 months [58]. A subsequent US RCT with 83 patients had patients write about daily stress [59]. Both reduction of sleep disorders and reduced health care use were observed 3 months after the writing intervention compared with a neutral time management treatment. Writing interventions led to a reduction of physical and psychological symptoms compared with control groups after the treatment and after 4-month follow-up. Reduced health care system use was found in one study. According to the

Guided imagery A Dutch RCT that compared patient education (n = 22), guided imagery (n = 19), and a free talk group (n = 17)

448

I


Figure 1. Hours of treatment and effect sizes of cognitive-behavioral therapy (CBT) and operant-behavioral therapy (OBT) in a fibromyalgia outpatient and inpatient setting. The effect sizes for treatment groups were computed based on the formula CG (mean T2–T4) – CBT/OTG (mean T2–T4)/CBT/OTG (SD T1). The regression does not include the inpatient study. (Data from Turner and Jensen [60].)

APS and AWMF guidelines on the diagnosis and treatment in FM, writing interventions may be used in addition to high-efficacy treatments such as CBT/OBT, cardiovascular exercises, and pharmacotherapy.

Effects of Psychoanalytic Therapy RCTs that show the efficiency of psychodynamic and psychoanalytic pain treatment in patients with FM have not been published, and thus the efficacy of psychoanalysis for FM treatment is not known.

Discussion These 32 published, high-quality RCTs suggest that treatment of FM patients should include CBT and OBT. These psychotherapeutic techniques reduced FM pain in 42% to 54% of CBT-treated and in 54% to 65% of OBT-treated FM patients in contrast to the mild effects of pharmacotherapy and physiotherapy [4,36••]. These differences in efficacy may be explained by the presence of augmented pain processing [12] that includes learned interactions between somatosensory, cognitive, affective, and behavioral factors influencing pain perception. In both CBT and OBT, patients learn to reduce maladaptive cognitions and pain behaviors and replace them with healthy and assertive pain-incompatible behaviors and cognitions. These treatments reduce both negative emotions, such as depression and affective distress, and pain perception, effects that have been associated with altered activity in brain regions. The changes in learning using methods such as classical and operant conditioning lead to changes of neurophysiologic parameters caused by treatment-related

changes of the behavioral, cognitive, affective, and sensory aspects of pain. In the sample of 14 CBT RCTs, 50% reported longterm changes of pain intensity, 21.4% short-term effects, and 28.6% no changes in pain intensity. Heterogeneous pain responses after CBT/OBT may be related to treatment duration. The studies achieving long-term changes in pain intensity presented a greater number (mean, 23 h; range, 12–36 h) of treatment hours in contrast to studies without any pain reduction that used only a mean of 9 hours (range, 6–12 h; P = 0.02). CBT involving fewer than 20 hours (range, 14–20 h) achieved short-term changes in pain intensity (P = 0.014). Effect sizes correlated with the number of treatment hours for outpatient studies (r = 0.45), shown by the regression line in Figure 1, and for all studies (r = 0.69). A further reason for long-term changes in pain may be related to the content of CBT. The most successful studies included a treatment aim of improved physical activity combined with training of healthy cognitions and behavior based on the model of augmented pain processing connected with classical and operant conditioning of pain. A third reason is associated with known predictors of the efficacy of psychological treatment. Patients with lower physical interference have a high probability for reduced pain intensity in response to behavioral methods. Patients with higher physical impairment, low affective distress, pain-reinforcing solicitous spouse behavior, and higher pain behaviors have a high probability for reduced physical impairment in response to behavioral methods. In contrast, patients who report low pain intensity but high affective distress and a greater number of physician visits have a high risk for deterioration of physical impairment after psychotherapy [23•]. These results have been reported in only one study and need to be replicated. Indication criteria are essential for the selection of available behavioral treatment modalities because of the heterogeneity of the FM patient population. Patients with high levels of pain-related interference combined with high levels of pain behaviors and catastrophizing, a high number of physician visits, and pain-reinforcing solicitous spousal behaviors will likely profit from OBT. In contrast, patients with a higher level of affective distress, reduced adaptive coping, less catastrophizing, low solicitous spouse behavior, and low pain behaviors may profit from CBT. Given the success of relaxation methods such as AT and JRT, and also the success of EMG-BFB in the treatment of low back pain, the low efficacy of these treatments in FM was unexpected. In contrast, hypnotherapy and writing interventions demonstrated modest efficacy in reducing FM pain. Future experimental studies are necessary to investigate if hypnotherapy and writing interventions influence pain-related emotion, cognition, and behavior.

Conclusions CBT and OBT are highly effective psychotherapeutic methods for treating FM pain. Individual interventions,


including relaxation, are not effective when applied as monotherapy. The reported treatment effects of biofeedback in FM are inconsistent. No studies have shown pain-reducing effects of psychoanalytic treatment. Matched interventions of CBT and OBT have been shown to normalize central nervous system plasticity and demonstrate superior probability for reduction of pain intensity and beneficial modification of maladaptive cognition and pain behavior.

Disclosure Dr. Gracely has received honoraria for consulting from Pierre-Fabre and stock options from Algynomics. No further potential confl icts of interest relevant to this article were reported.

References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

Wolfe F: The epidemiology of fi bromyalgia. In Musculoskeletal Pain, Myofascial Pain Syndrome, and the Fibromyalgia Syndrome. Edited by Jacobsen S, Danneskiold-Samsøe B, Lund B. London, UK: The Haworth Press; 1993:137–148. 2. Arnold LM, Keck PE Jr, Welge JA: Antidepressant treatment of fibromyalgia: a meta-analysis and review. Psychosom 2000, 41:104–113. 3. Papadopoulos IA, Georgiou PE, Katsimbri PP, Drosos AA: Treatment of fibromyalgia with tropisetron, a 5HT3 serotonin antagonist: a pilot study. Clin Rheumatol 2000, 19:6–8. 4. O’Malley P, Balden E, Tomkins G, et al.: Treatment of fibromyalgia with antidepressants: a meta-analysis. J Gen Intern Med 2000, 15:659–666. 5. Wolfe F, Smythe HA, Yunus MB, et al.: The American College of Rheumatology 1990. Criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990, 33:60–172. 6.• Bennett RM, Jones J, Turk DC, et al.: An internet survey of 2596 people with fibromyalgia. BMC Musculoskelet Disord 2007, 8:27. This article discusses a large and very interesting internet survey presenting information on demographics, sources of information, symptoms, function, perceived aggravating factors, perceived triggering events, health care utilization, management strategies, and medication use. The descriptive data identified several issues for further research, such as the prescribing habits of FM health care providers. 7. Winfield J: Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain 2000, 4:276–286. 8. Gracely RH, Geisser ME, Giesecke T, et al.: Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 2004, 127:835–843. 9. Thieme K, Turk DC, Flor H: Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables. Psychosom Med 2004, 66:837–844. 10. Sorensen J, Graven-Nielsen T, Henriksson KG, et al.: Hyperexcitability in fibromyalgia. J Rheumatol 1998, 25:152–155. 11. Klauenberg S, Maier C, Assion HJ, et al.: Depression and changed pain perception: hints for a central disinhibition mechanism. Pain 2008, 140:332–343.

12.

I

Thieme and Gracely

I

449

Gracely RH, Petzke F, Wolf JM, Clauw DJ: Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum 2002, 46:1333–1343. 13.•• Bennett R, Nelson D: Cognitive behavioral therapy for fibromyalgia. Nat Clin Prac 2006, 2:416–424. This excellent review analyzed the results from 13 programs using CBT alone or in combination with other treatment modalities. In most studies, CBT provided worthwhile improvements in pain-related behavior, self-efficacy, coping strategies, and overall physical function. The authors suggest that CBT could be included in a multidimensional approach. 14. Beck AT: Thinking and depression. I. Theory and therapy. Arch Gen Psychiatry 1964, 10:561–571. 15. Ellis A: New approaches to psychotherapy techniques. J Clin Psychol 1955, 11:207–260. 16. Meichenbaum D: Cognitive-Behavior Modifi cation: An Integrative Approach. New York: Plenum; 1977. 17. Turk DC, Okifuji A, Sinclair JD, Starz TW: Differential responses to psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment. Arthritis Care Res 1998, 11:397–404. 18. Burckhardt CS, Mannerkopi K, Hedenberg L, Bjelle A: A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994, 21:714–720. 19. Williams DA, Cary MA, Groner KH, et al.: Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatol 2002, 29:1280–1286. 20. Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, et al.: Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. I. Clinical effects. J Rheumatol 1996, 23:1237–1245. 21. Kashikar-Zuck S, Swain NF, Jones BA, Graham TB: Efficacy of cognitive-behavioral intervention for juvenile primary fibromyalgia syndrome. J Rheumatol 2005, 32:1594–1602. 22. Bennett RM, Burckhardt CS, Clark SR, et al.: Group treatment of fi bromyalgia: a 6 month outpatient program. J Rheumatol 1996, 23:521–528. 23.• Thieme K, Flor H, Turk DC: Psychological pain treatment in fibromyalgia syndrome: efficacy of operant behavioral and cognitive behavioral treatments. Arthritis Res Ther 2006, 8:R121. This study shows that direction and magnitude of treatment effects depend on the treatment method. In addition to demonstrating the benefits of CBT and OBT, the results suggest that unstructured discussion of FM-related problems, typical of patient–physician communications, may actually be detrimental. 24. Fordyce WE: Behavioral Methods in Chronic Pain and Illness. St. Louis, MO: Mosby; 1976. 25. Labus JS, Keefe FJ, Jensen MP: Self-reports of pain intensity and direct observations of pain behavior: when are they correlated? Pain 2003, 102:109–124. 26. Vlayen JWS, Van Eyk H, Groenman NH, Schuerman JA: Dimensions and components of observed chronic pain behavior. Pain 1987, 31:65–75. 27. Romano JM, Turner JA, Friedman LS, et al.: Sequential analysis of chronic pain behaviors and spouse responses. J Consult Clin Psych 1992, 60:777–782. 28. Baumstark KE, Buckelew SP, Sher KJ, et al.: Pain behavior predictors among fibromyalgia patients. Pain 1993, 55:339–346. 29. Flor H, Breitenstein C, Birbaumer N, et al.: A psychophysiological analysis of spouse solicitousness towards pain behaviors, spouse interaction and pain perception. Behavior Therapy 1995, 26:255–272. 30. Flor H, Knost B, Birbaumer N: The role of operant conditioning in chronic pain: an experimental investigation. Pain 2002, 95:111–118. 31. Turk DC, Okifuji A, Starz TW, Sinclair JD: Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients. Pain 1996, 68:423–430.

450 32.

I


Romano JM, Turner JA, Jensen MP, et al.: Chronic pain patient-spouse behavioral interactions predict patient disability. Pain 1995, 63:353–360. 33. Thieme K, Gromnica-Ihle E, Flor H: Operant behavioral treatment of fibromyalgia: a controlled study. Arthritis Rheum 2003, 49:314–320. 34. Nicassio PM, Radojevic V, Weisman MH, et al.: A comparison of behavioral and educational interventions for fibromyalgia. J Rheumatol 1997, 24:2000–2007. 35. Thieme K, Spies C, Sinha P, et al.: Predictors of pain behaviors in fibromyalgia patients. Arthritis Rheum 2005, 53:343–350. 36.•• van Koulil S, Effting M, Kraaimaat FW, et al.: A review of cognitive behaviour therapies and exercise programmes for fibromyalgia patients: state of the art and future directions. Ann Rheum Dis 2006, 66:571–581. This review of nonpharmacologic treatments for patients with FM suggests that efficacy may be enhanced by offering tailored treatment approaches at an early stage to patients. 37. Redondo JR, Justo CM, Moraleda FV, et al.: Long-term efficacy of therapy in patients with fibromyalgia: a physical exercise-based program and a cognitive-behavioral approach. Arthritis Rheum 2004, 51:184–192. 38. Keel PJ, Bodoky C, Gerhard U, et al.: Comparison of integrated group therapy and group relaxation training for fibromyalgia. Clin J Pain 1998, 14:232–238. 39. Wigers SH, Stiles TC, Vogel PA: Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study. Scand J Rheumatol 1996, 25:77–86. 40. Garcia J, Simon MA, Duran M, et al.: Differential efficacy of a cognitive-behavioral intervention versus pharmacological treatment in the management of fibromyalgic syndrome. Psychol Health Med 2006, 11:498–450. 41. Soares JJF, Grossi G: A randomised, controlled comparison of educational and behavioral interventions for woman with fibromyalgia. Scand J Occup Ther 2002, 9:35–45. 42. De Voogd JN, Knipping AA, de Blécourt ACE, et al.: Treatment of fibromyalgia syndrome with psychomotor therapy and marital counselling. J Musculoskel Pain 1993, 1:273–281. 43.•• Thieme K, Turk DC, Flor H: Responder criteria for operant and cognitive-behavioral treatment of fibromyalgia syndrome. Arthritis Rheum 2007, 57:830–836. This article provides a very useful comparison of the clinical significance of CBT, OBT, and social discussion treatments. The study suggests that pretreatment patient characteristics are important predictors of treatment response and may serve as a basis for matching treatments to patient characteristics. 44. Sinclair VG, Wallston KA: Predictors of improvement in a cognitive-behavioral intervention for women with rheumatoid arthritis. Ann Behav Med 2001, 23:291–297. 45. Rucco V, Feruglio C, Genco F, Mosanghini R: Autogenic training versus Erickson’s analogical technique in treatment of fibromyalgia syndrome. Riv Eur Sci Med Farmacol 1995, 17:41–50.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

Guenther V, Mur E, Kinigadner U, Miller C: Fibromyalgia: the effect of relaxation and hydrogalvanic bath therapy on the subjective pain experience. Clin Rheumatol 1994, 13:573–578. Field T, Diego M, Cullen C, et al.: Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J Clin Rheumatol 2002, 8:72–76. Hammond A, Freeman K: Community patient education and exercise for people with fibromyalgia: a parallel group randomized controlled trial. Clin Rehabil 2006, 20:835–846. Ferraccioli G, Ghirelli L, Scita F, et al.: EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol 1987, 14:820–825. Buckelew SP, Conway R, Parker J, et al.: Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial. Arthritis Care Res 1998, 11:196–209. van Santen M, Bolwijn P, Verstappen F, et al.: A randomized clinical trial comparing fitness and biofeedback training versus basic treatment in patients with fibromyalgia. J Rheumatol 2002, 29:575–581. Kravitz HM, Esty ML, Katz RS, et al.: Treatment of fibromyalgia syndrome using low-intensity neurofeedback with the flexyx neurotherapy system: a randomized controlled clinical trial. J Neurotherapy 2006, 10:41–58. Drexler AR, Mur EJ, Guenther VC: Efficacy of an EMGbiofeedback therapy in fibromyalgia patients. A comparative study of patients with and without abnormality in (MMPI) psychological scales. Clin Exp Rheumatol 2002, 20:677–682. Haanen HC, Hoenderdos HT, van Romunde LK, et al.: Controlled trial of hypnotherapy in the treatment of refractory fi bromyalgia. J Rheumatol 1991, 18:72–75. Fors EA, Goetestam KG: Patient education, guided imagery and pain related talk in fibromyalgia coping. Eur Psychiatry 2000, 14:233–240. Fors EA, Sexton H, Gotestam KG: The effect of guided imagery and amitriptyline on daily fibromyalgia pain: a prospective, randomized, controlled trial. J Psychiatr Res 2002, 36:179–187. Menzies V, Taylor AG, Bourguignon C: Effects of guided imagery on outcomes of pain, functional status, and selfefficacy in persons diagnosed with fibromyalgia. J Altern Complement Med 2006, 12:23–30. Broderick JE, Junghaenel DU, Schwartz JE: Written emotional expression produces health benefits in fibromyalgia patients. Psychosom Med 2005, 67:326–334. Gillis ME, Lumley MA, Mosley-Williams A, et al.: The health effects of at-home written emotional disclosure in fibromyalgia: a randomized trial. Ann Behav Med 2006, 32:135–146. Turner JA, Jensen MP: Efficacy of cognitive therapy for chronic low back pain. Pain 1993, 52:169–177.