Cognitive Behavioural Therapy (CBT) Treatments for Fibromyalgia
- 1 Definiton
- 2 Efficacy
- 3 Underlying psychological issues in need of correction
- 4 Bennett and Nelson’s key strategies for the use of CBT in fibromyalgia
- 5 Luciano et al.’s CBT program
- 6 Benefits of CBT for brain connectivity in fibromyalgia
- 7 The challenge ahead to further refine CBT for fibromyalgia
- 7.1 Introducton
- 7.2 Defining the key underlying issues
- 7.3 Generic and customized components
- 7.4 Addition of Cognitive behaviour therapy for pain (CBT-P)
- 7.5 Addition of Cognitive Behavioural Therapy for Catastrophizing in General
- 7.6 Cognitive Behavioural Therapy for Hypervigilance (CBT-H)
- 8 The problem of hypervigilant young mothers
This is a “short-term, goal-oriented” for of psychotherapy that emphasizes techniques aimed at the correction of “thought patterns and behaviors rather than providing 'deep insight'” often in a string of 10-20 sessions. (Cognitive behavioral therapy for fibromyalgia. Bennett R1, Nelson D. Nat Clin Pract Rheumatol. 2006 Aug;2(8):416-24.) It is often done on a one-to-one basis but can be done with group sessions.
Fibromyalgia is one of several chronic pain conditions that it has been used to treat.
A review by Bennett et al. concluded that most studies found that it “provided worthwhile improvements in pain-related behavior, self-efficacy, coping strategies and overall physical function. Sustained improvements in pain were most evident when individualized CBT was used to treat patients with juvenile fibromyalgia. The current data indicate that CBT, as a single treatment modality, does not offer any distinct advantage over well-planned group programs of education or exercise, or both.”
[Author’s comments: In my opinion, it is safe to assume that in the future, improved individualized forms of CBT have much greater potential than a “one size fits all approach”.]
Underlying psychological issues in need of correction
There some issues that are common to very large percentage of fibromyalgia patients such as the tendency towards worrying when trying to get to sleep with each worrisome thought leading to another, and each one serving to agitate the patient and postpone falling asleep. A CBT technique which interrupts this pattern and is taught in a group makes sense.
It is however, commonplace (based on the author’s review of 130 of his own in-depth case histories) for patients to have their own unique very specific issues. Examples include the young woman who feels jilted by her lover, or the middle-aged woman who is contemplating a second divorce, or the teacher’s assistant who was knocked over by a child in the school yard, then fell to the ground and poked her eye. This resulted in a loss of vision in it. She went on to develop PTSD with falling nightmares. Even if the people in all three of these examples developed insomnia and a non-restorative sleep pattern as a result, clearly each one needed an individualized approach like CBT or psychoanalysis for their specific issues and not just a general standardized group CBT for their insomnia.
Bennett and Nelson’s key strategies for the use of CBT in fibromyalgia
(Paraphrased and quoted from Bennett and Nelson. See: Cognitive behavioral therapy for fibromyalgia Robert Bennett* and David Nelson, Nature Clinical Practice Rheumatology, August 2006 VOL 2 NO 8, available in full online at: http://www.myalgia.com/PDF%20files/Bennett%20Nelson%20CBT%202006.pdf.)
■ Educate the patient on the nature of fibromyalgia. Include an explanation of the concepts of central sensitization, central pain processes and the various interactions “between emotions, behavior and cognition in coping and functioning”.
■ Work with the patient to set realistic goals “for work or work-like activities, social activities, and involvement with family and friends”.
■ Provide relaxation training such as progressive muscle relaxation training or controlled diaphragmatic breathing. [One type preferred by the author of this Encyclopedia is the so called “4-7-8 method. It is useful during the day periodically as needed to interrupt or prevent a session of worrying. It is also a useful part of CBT-insomnia (CBT-I), especially when closing one’s eyes after getting into bed so as to begin the process of relaxation which is so necessary to fall asleep. For Dr. Weil’s YouTube video see: https://www.drweil.com/videos-features/videos/breathing-exercises-4-7-8-breath/
■ Assist the patient in planning for proper “behavioral pacing of activities to not overdo or underdo activity levels”.
■ Work with the patient to identify their principle dysfunctional thought patterns. [Often these take the form of negative thought patterns during the day or when trying to fall asleep. They can involve complex interpersonal conflicts.]
■ Develop a plan to help the patient “to counter negative automatic thoughts, and the underlying maladaptive attitudes or beliefs fueling these thoughts”
■ Communication skills training, so as to try to enhance appropriate assertiveness thus permitting a “corresponding release of tension from controlling and bottling up negative thoughts and feelings, and enhance interactions with health-care providers and others.”
■ Strategies for acquisition, maintenance, and generalization of skills.
■ Strategies for relapse prevention and for managing painful flare-ups.
Luciano et al.’s CBT program
Results and benefits
Test subjects scored comparatively better results than controls of the EuroQoL-5D visual analogue scale (EQ-VAS). (For more on this tests see: [EuroQol-5D (EQ-5D): an instrument for measuring quality of life]. [Article in Italian] Balestroni G1, Bertolotti G. Monaldi Arch Chest Dis. 2012 Sep;78(3):155-9.) This is a quality of life assessment tool. It is a “descriptive system”. It is “a preference-based HRQL measure with one question for each of the five dimensions that include mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.”
Luciano et al. state: “Because of lower costs, CBT is the most cost-effective treatment for adult FM patients.” (Cost-utility of cognitive behavioral therapy versus U.S. Food and Drug Administration recommended drugs and usual care in the treatment of patients with fibromyalgia: an economic evaluation alongside a 6-month randomized controlled trial. Luciano JV, D'Amico F, Cerdà-Lafont M, Peñarrubia-María MT, Knapp M, Cuesta-Vargas AI, Serrano-Blanco A, García-Campayo J. Arthritis Res Ther. 2014 Oct 1;16(5):451 available in full online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203881/.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated).
Introduction to Luciano’ program
Luciano et al. conducted a study of CBT in fibromyalgia. It was highly structured. It consisted of a series of sessions with up to 8 patients per group.
Key aspects of the Luciano approach
- Patients were assigned to practice what they learned and they were given “homework tasks with the goal of fostering practice of the skills outside of the sessions”.
- They were encouraged to adopt new “behaviours and ways of thinking” and to “learn what types of coping strategies work best for them”.
- They were asked “to identify automatic, negative thoughts”. They were asked to identify “cognitive errors, and to review problems in implementing skills outside the safe environment of the CBT group”. In other words, patients were expected to be active players in their own care and expected to try make appropriate changes in their personal psychology.
- Structured techniques were used to alter distorted thoughts.
- Patients were expected to acquire and practice cognitive skills and emotion-regulation skills.
- The CBT utilized a pain-self management paradigm.
- They identified and sought to reduce catastrophizing which was seen by the authors as a type of maladaptive pain-related cognitions. This was done using several techniques including relaxation, visual imagery, thought challenging, and distraction. Patients practiced the techniques during the session. They were also expected to practice them at home with the help of written exercises.
- A technique known as cognitive restructuring was utilized to assist the patients in understanding the relationships between thoughts, feelings and behaviors.
The patients were taught to “identify, evaluate, and challenge negative thoughts and to diminish the degree of catastrophizing about pain.”
Session outlines for the Cognitive Behavioral Therapy (CBT) group treatment protocol by Luciano et al.
- Discussing the connection between stress and pain
- Identification of automated, negative thoughts
- Evaluation of automated, negative thoughts
- Challenging the automatic, negative thoughts and constructing alternatives
- Nuclear beliefs
- Nuclear beliefs about pain
- Changing coping strategies
- Coping with ruminations-obsessions-worrying. Session focused on pain catastrophizing.
- Expressive writing and assertive communication
This is table 1 from: Cost-utility of cognitive behavioral therapy versus U.S. Food and Drug Administration recommended drugs and usual care in the treatment of patients with fibromyalgia: an economic evaluation alongside a 6-month randomized controlled trial. Luciano JV, D'Amico F, Cerdà-Lafont M, Peñarrubia-María MT, Knapp M, Cuesta-Vargas AI, Serrano-Blanco A, García-Campayo J.Arthritis Res Ther. 2014 Oct 1;16(5):451 available in full online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203881/. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/. For a direct link to this table go to: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203881/table/Tab1/)
Benefits of CBT for brain connectivity in fibromyalgia
Lararidou et al.’s use of CBT-I in fibromyalgia had proven beneficial impact on brain connectivity between two area of the brain that are known to be involved in fibromyalgia (the S1 area and the insula.) (Effects of Cognitive-Behavioral Therapy (CBT) on brain connectivity supporting catastrophizing in fibromyalgia. Asimina Lazaridou, Ph.D.,1 Jieun Kim,2,3 Christine M. Cahalan,1 Marco L. Loggia,1,2 Olivia Franceschelli,1 Chantal Berna,1 Peter Schur,4 Vitaly Napadow,1,2,# and Robert R. Edwards1,#Clin J Pain. 2017 Mar; 33(3): 215–221. doi: 10.1097/AJP.0000000000000422, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296218/.)
A study by McCrae et al in 2018 discovered very interesting evidence to support the idea that CBT-I may slow or reverse cortical gray matter atrophy in patients with fibromyalgia and insomnia. (Gray Matter Changes Following Cognitive Behavioral Therapy for Patients With Comorbid Fibromyalgia and Insomnia: A Pilot Study. McCrae CS, Mundt JM, Curtis AF, Craggs JG, O'Shea AM, Staud R, Berry RB, Perlstein WM, Robinson ME., J Clin Sleep Med. 2018 Sep 15;14(9):1595-1603. doi: 10.5664/jcsm.7344, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134244/.) This is a very exciting development because it suggests that psychotherapy can repair brain tissue. Their best results were in the left lateral orbitofrontal cortex, left rostral middle frontal cortex.
Another study by McCrae et al one year later in 2019 showed that both cognitive behavioural therapy for insomnia (CBT-I) and cognitive behavioural therapy for pain (CBT-P) both “improved insomnia symptoms immediately and 6 months following treatment.” After 6 months approximately half patients in from both treatment groups “no longer reported difficulties initiating and maintaining sleep.”long-term pain reduction in some patients.” (Cognitive behavioral treatments for insomnia and pain in adults with comorbid chronic insomnia and fibromyalgia: clinical outcomes from the SPIN randomized controlled trial.Christina S McCrae,1 Jacob Williams,2 Daniela Roditi,2 Ryan Anderson,2 Jennifer M Mundt,2 Mary Beth Miller,1 Ashley F Curtis,1 Lori B Waxenberg,2 Roland Staud,3 Richard B Berry,4 and Michael E Robinson2 Sleep. 2019 Mar; 42(3): zsy234.doi: 10.1093/sleep/zsy234, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424087/.)
The treatment involved the following CBT-I treatments (and this is instructive for future patients):
- Eight sessions, once a week
- Sessions were individualized (no one-size-fits-all approach)
- Sessions were 50 minutes (in other words, they were substantial)
- Sessions by a psychologist
- Patients were given take home work books with rationales (this is important because to be willing to work hard a patient needs a reason to believe in it)
- Patients expected to work at home (not just casually drop in once a week to the psychologist)
- One session on each of the standard elements of CBT-I (sleep hygiene, stimulus control, autogenic relaxation, sleep restriction)
- Three sessions of cognitive therapy.
- Long-term review and maintenance session.
Please consult the original paper for further details.
The challenge ahead to further refine CBT for fibromyalgia
The approach taken to use CBT to treat the fibromyalgia is very sensible. There are good opportunities to make it even better.
Author’s opinion on creating a new practice guideline for the addition of CBT for insomnia (CBT-I) for most patients with fibromyalgia
Almost all fibromyalgia patients have significant sleep problems. Poor sleep is a major aggravating factor for fibromyalgia. There is a specialized form of CBT for insomnia called CBT-I. In the opinion of the author, based on multiple published reports and clinical experience using CBT-I in fibromyalgia patients, it should be the standard practice for most patients.
(There may be a few exceptions such as patients with fibromyalgia who do not have insomnia or light sleep, but their problem is inadequately treated sleep apnea. (This occurs for example when patients cannot or will not wear their mask.)
In my experience, patients that stick with CBT-I often see clear improvement in their fibromyalgia symptoms, especially their associated fatigue, but also to some degree, with their pain. This include five standard components. For an overview by a mainstream source see: http://sleepeducation.org/treatment-therapy/cognitive-behavioral-therapy.
Moldofsky’s suggested practice guideline for assessment of the cause of non-restorative sleep in fibromyalgia
According to Moldofsky, fibromyalgia treatment “requires a proper assessment of the reason for the unrefreshing sleep, which is an important component of the FM syndrome.” (Management of sleep disorders in fibromyalgia. Harvey Moldofsky 1 Rheum Dis Clin North Am. . 2002 May;28(2):353-65, DOI: 10.1016/s0889-857x(01)00012-6.) Based on extensive frontline clinical experience, many cases of non-fleshing sleep involve what patients describe as light sleep or “sleeping with one ear open”. Based on clinical experience, and surveys of nocturnal hypervigilance, it is the author’s strong impression that this an important factor. Many admit to watching out for dangers during their sleep. The time is ripe to create a CBT module for nocturnal hypervigilance for patients that upon screening are suffering from it. In the opinion of the author this should be part of their CBT program. I call it CBT-NV.
Defining the key underlying issues
Without a rational and prioritized list of key underlying issues as to what is causing, precipitating, exacerbating and relieving a patient’s disorder, it is very difficult to design an optimal CBT program for them. Most or all patients have sleep disorders. Insomnia is rampant, especially occurring as difficulty and delay in initiating sleep due to racing thoughts. Any CBT program that overlooks this or other critical issues is unlikely to be optimally successful.
Generic and customized components
Current CBT approaches can be somewhat hit and miss because some patients have serious, but uncommon issues that are very individual to them which are not well addressed by a one size fits all approach. I recommend the following approach. For each patient there should be two parts: a CBT program that is the same for all patients which covers topics and issues that are believed to be applicable to most or all fibromyalgia patients. The second part is a customized program designed for issues that are important and specific or relatively specific to them. Luciano et al.’s study and others like it have important implications for psychoanalysis and other forms of psychotherapy, which has long struggled for proof of efficacy. In the past the tools were not there to show proof objectively; but this is all changing.
Here are a few of many possible examples of situation in which there may be a need for individualized psychotherapy to accompany a CBT package:
- A patient with a conflict over falling that developed their fibromyalgia after a fall.
- A woman who developed fibromyalgia when she had a sick baby and she began to sleep lightly while listening to their baby’s every breath for indicators danger.
Addition of Cognitive behaviour therapy for pain (CBT-P)
While work by McCrae et al. showed even greater benefits for CBT-I, there is a case to be made in favor of doing both. Furthermore, both are a work in progress which means they can be refined.
Addition of Cognitive Behavioural Therapy for Catastrophizing in General
To date, the focus on catastrophizing in fibromyalgia has been on catastrophizing of the pain. However, catastrophizing is more general phenomenon. It is essentially a form of evaluative processing whereby problems and magnified into disasters. As such, it is a thinking problem involving exaggeration of evil. This could be tested by questioning the patient informally, or designing questionnaires. If in fibromyalgia it turns out to be a more general than just relating to the pain, it would be logical to consider creating a CBT module for catastrophizing in general (CBT-Cig) as opposed to CBT for pain catastrophizing of pain.
Cognitive Behavioural Therapy for Hypervigilance (CBT-H)
(Term coined by Dr. Mark Doidge, 2020)
This is a treatment idea with no published reports as of 2020 It should be considered a work in progress that is currently in its early stages. In the opinion of the author it could be refined by contributions from psychologists, especially if they get experience interviewing patients with this problem.
It is well-known fact that fibromyalgia patients tend to wake to the slightest sound. The author has now reaffirmed this dozens of times in his clinical practice bases on studying the results of hypervigilance questionnaires done by fibromyalgia patients and based on dozens of interviews.
Author’s suggestions for treatment of hypervigilance in fibromyalgia:
- Ensure the patient understands that this is generally a psychological issue that will require them to make an effort to change their psychology.
- Focus the effort on psychological counselling to assist to patient to improve their sense of safety and physical security; The motto is “Get to safe.” This means that the patient is encouraged to find ways to feel safer. This goes well beyond safely measures. The safety factor can be personal as when light sleep starts after moving into a dangerous neighborhood. Or, it can relate to a loved one, especially a young mother guarding her baby at night by listing half-awake to its every breath.
- Have all patients fill out the daytime and nighttime hypervigilance form, then schedule an hour discussion based on each answer in which they indicated a substantial issue by having marked it as occurring often
- Anyone with a high score with moderate to severe insomnia or fibromyalgia should be offered customized psychotherapy or what shall be referred to here as CBT-H or cognitive behavioural therapy for hypervigilance.
- Patients and their therapists should read the entry in this wiki on Danger Mode
- Individualize the therapy based on the main suspected underpinnings.
An example is if the patient began to feel unsafe and sleep lightly in childhood because of chaos or perceived dangers in the home.
The problem of hypervigilant young mothers
An example is the young mother who developed hypervigilance about the safety of her baby and light sleep when she had an ill child with a breathing problem. Some mothers seem to subconsciously overanalyze each breath sound of their baby for indicators of danger such as coughing wheezing so that she can wake up immediately to save the baby if needed.
There is a delicate balance that needs to be achieved. Of course, mothers need to watch out. The problem arises if they have not support and they are becoming exhausted. Night after night of reduced sleep and light sleep can accumulate to create a crisis. There is nothing more natural than a mother trying to protect her young.
Some mothers continue waking to the slightest sound even with ear plugs are on many years after the baby has grown up and has long been safe.
While waiting for further research the author suggests that the therapist attempt to enlist the support of the patient to undertake a gradual campaign to regain the personal sense of safety. In cases of past physical and sexual abuse, this can be a tall order.
It is difficult to know if security technology could help such as motion detectors to monitor for intruders. If the patient finds this reassuring then perhaps it could help.
One approach to designing individualized psychotherapy is to isolate any answers on the questionnaire that the patient listed as occurring often, then to discuss them in detail and strategize with the patient how they could be corrected.