Cognitive Behavioural Therapy for Insomnia (CBT-I) in Fibromyalgia
- 1 Introduction
- 2 What is CBT-I?
- 3 CBT-I as the initial treatment of choice for insomnia
- 4 Common treatments of insomnia that have been judged by the European Sleep Society as being sub-optimal
- 5 The need for expanded training of health care professionals in CBT-I
- 6 Limitations of CBT-I
- 7 Rationale for using CBT-I in patients with fibromyalgia
- 8 Other forms of CBT in the treatment of fibromyalgia
- 9 Neural substrate for improvements in the brain due to CBT in fibromyalgia
- 10 Author’s opinion on the future of CBT in the treatment of fibromyalgia
- 11 Further information
This relates to pain treatment in general and fibromyalgia treatment in particular because there is often a close and important clinical relationship between poor sleep and the pain of fibromyalgia. Pain can interfere with sleep, and many fibromyalgia patients report increased pain after a poor night of sleep. Furthermore, it is commonplace to fibromyalgia patients to say that if the do manage to have the occasional good night of sleep, their pain is better. For these reasons, the repair of sleep is one of the bright lights for the treatment of fibromyalgia.
What is CBT-I?
This is a specialized behavioural-psychological treatment for insomnia consisting of a collection of pieces of advice to the patient aimed at overcoming their psychological barriers to falling asleep and to help sleeping well. As of 2020, the standard package has 5 parts. For a concise description of CBT-I see: What is (CBT-I)? http://sleepeducation.org/treatment-therapy/cognitive-behavioral-therapy.
CBT-I as the initial treatment of choice for insomnia
As of 2020, it was widely recommended by leading organizations of sleep experts as the front-line treatment of choice for insomnia. (See the European guideline at: European guideline for the diagnosis and treatment of insomnia. Dieter Riemann, Chiara Baglioni, Claudio Bassetti, Bjørn Bjorvatn, Leja Dolenc Groselj. Jason G. Ellis , Colin A. Espie. Diego Garcia‐Borreguero. Michaela Gjerstad, Marta Gonçalves, Elisabeth Hertenstein , Markus Jansson‐Fröjmark, Poul J. Jennum, Damien Leger, Christoph Nissen, Liborio Parrino, Tiina Paunio, Dirk Pevernagie, Hans‐Günter Weeß, Adam Wichniak, Irina Zavalko, Erna S. Arnardottir, Oana‐Claudia Deleanu, Barbara Strazisar, Marielle Zoetmulder, Kai Spiegelhalder. Journal of Sleep Research: Volume26, Issue6, December 2017. Pages 675-700: 05 September 2017, https://doi.org/10.1111/jsr.12594, available in full online at: https://onlinelibrary.wiley.com/doi/full/10.1111/jsr.12594. This guideline for chronic insomnia states that the strongly recommended first line treatment for chronic insomnia for adults of any age is CBT-I and that the evidence for this was described as “high-quality”. As for drug treatment, they advised that this should be offered when CBT-I is not sufficiently effective or available. “Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short‐term treatment of insomnia (≤4 weeks; weak recommendation, moderate‐quality evidence).”
The AASM Guideline which is a leading organization of US experts, states can be found at: Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. In 2021 it released six recommendations for adult treatment of chronic insomnia. Based on available evidence, only on rose to the level of being a strong recommendation. This states: “We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG)” (Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline, Jack D. Edinger, PhD, J. Todd Arnedt, PhD, Suzanne M. Bertisch, MD, MPH, Colleen E. Carney, PhD, John J. Harrington, MD, MPH, Kenneth L. Lichstein, PhD, Michael J. Sateia, MD, FAASM, Wendy M. Troxel, PhD, Eric S. Zhou, PhD, Uzma Kazmi, MPH, Jonathan L. Heald, MA, Jennifer L. Martin, PhD, Journal of Clinical Sleep Medicine Volume 17, Issue 2, Published Online: February 1, 2021 available in full online at: https://jcsm.aasm.org/doi/10.5664/jcsm.8986
Common treatments of insomnia that have been judged by the European Sleep Society as being sub-optimal
European Sleep Society found that a number of commonly used over the counter drugs, and prescription drugs, specifically, antihistamines, antipsychotics, melatonin were not effective. Nor were phytotherapeutics which was described as “not recommended for insomnia treatment (strong to weak recommendations, low‐ to very‐low‐quality evidence).”
The need for expanded training of health care professionals in CBT-I
[Author’s comment: As of 2020, in countries such as Canada, most patients with chronic insomnia are still not getting CBT-I. Given the frequency of insomnia as a disorder, and its far-reaching effects on a person, and given its effectiveness, there is a strong argument that it should be standard part of medical training, nurse practitioner training and clinical psychology training. As of 2020, there is a major shortage of CBT-I therapists and in countries such as Canada, an even greater shortage of people who are insured to receive the treatment.]
Limitations of CBT-I
[Author’s opinion: CBT-I is not a panacea: It is not a quick fix and so it often won’t work for patients that demand a quick fix, with the possible exception of some minor cases. It calls for co-operation, time commitment and personal responsibility on the part of the patient. Language barriers and cognitive impairment can make it challenging to deliver. In the experience of the author, in very advanced cases of severe insomnia, it is more difficult to be successful.
Another limitation to the current standard package of CBT-I as of 2021, is that it its current formulation, it is not well designed to deal with light sleep as in the non-restorative sleep pattern which is so important in fibromyalgia.
Another limitation of standard packages of CBT-I is that in some people, deeply rooted complex psychological issues are the main driver for the insomnia, and these may require a more in-depth approach such as psychotherapy or psychoanalysis.]
Rationale for using CBT-I in patients with fibromyalgia
The basic case for CBT-I in fibromyalgia
The overwhelming majority of fibromyalgia patients have sleep disorders. Insomnia is very common in fibromyalgia. Fibromyalgia patients often say that their pain comes together with their fatigue. Furthermore, it is common for them to find that a night of especially poor sleep will exacerbate their pain. It is therefore logical to attempt to improve fibromyalgia pain by trying to repair the patient’s sleep.
Edinger’s first study
The first study of the use of CBT-I in fibromyalgia seems to have been done by Edinger et al. in 2005. (Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial, Jack D Edinger 1, William K Wohlgemuth, Andrew D Krystal, John R Rice Arch Intern Med . 2005 Nov 28;165(21):2527-35. doi: 10.1001/archinte.165.21.2527, https://pubmed.ncbi.nlm.nih.gov/16314551/ and available in full online at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/48682. It “compared CBT with an alternate behavioral therapy and usual care for improving sleep and other fibromyalgia symptoms”. “The study compared CBT, sleep hygiene (SH) instructions, and usual FM care alone.” Two licensed male clinical psychologists (W.K.W. and J.D.E.) provided CBT and SH therapy. This was guided by the study’s treatment manual. Patients got 6 weekly sessions. For details of the treatment, consult the original article.
Outcome measures were subjective (sleep logs) and objective (actigraphy) total sleep time, sleep efficiency, total wake time, sleep latency, wake time after sleep onset, and questionnaire measures of global insomnia symptoms, pain, mood, and quality of life.
Results were as follows:
- “The sleep hygiene therapy patients showed favorable outcomes on measures of pain and mental well-being. This finding was most notable in a sleep hygiene therapy subgroup that self-elected to implement selected CBT strategies.”
- “Sleep logs showed CBT-treated [fibromyalgia] patients achieved nearly a 50% reduction in their nocturnal wake time by study completion, whereas SH therapy- and usual care-treated patients achieved only 20% and 3.5% reductions on this measure, respectively.”
- Furthermore “(57%) of 14 CBT recipients met strict subjective sleep improvement criteria by the end of treatment compared with 2 (17%) of 12 SH therapy recipients and 0% of the usual care group.”
In essence, the study offers initial evidence that CBT for sleep in fibromyalgia is promising. (Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial. Edinger JD, Wohlgemuth WK, Krystal AD, Rice JR. Arch Intern Med. 2005 Nov 28;165(21):2527-35, available in full at: http://archinte.jamanetwork.com/article.aspx?articleid=486821.)
A study by Martinez et al. of women with both fibromyalgia and insomnia has found “significant improvements at post-treatment in several sleep variables, fatigue, daily functioning, pain catastrophizing, anxiety and depression.” (Cognitive-behavioral therapy for insomnia and sleep hygiene in fibromyalgia: a randomized controlled trial. Martínez MP et al. J Behav Med. 2013 Jun 7, available in full online at: https://www.researchgate.net/publication/237070336_Cognitive-behavioral_therapy_for_insomnia_and_sleep_hygiene_in_fibromyalgia_A_randomized_controlled_trial.) The CBT-I program was based on the work of Edinger et al. (2005) and met the recommendations of the American Academy of Sleep Medicine (Morgenthaler et al., 2006). It was broken into sessions. The first one focused on teaching the patient about the relationship between fibromyalgia and sleep as well as on sleep hygiene education. In the second session, patients were instructed on sleep restriction and stimulus control and asked to complete the sleep diary before initiating sleep restriction. The patient’s sleep efficiency was calculated based on the sleep diary data. Restriction of time in bed was established. Bedtime and time to get up were established. In the third session training was given on physiological deactivation procedures using slow breathing and passive relaxation and imagery training). Sessions 4 and 5 focused on cognitive therapy in order to try to change negative thoughts about insomnia through discussion and behavioural experiments. Session 6 was about maintaining achievements and preventing relapses.
[Author’s comments on the Martinez et al. study: This is a very good start and a far cry from the usual situation in fibromyalgia care where all too often no attention is paid. Time allowing, the CBT-I could be greatly improved by giving the patient a major assessment of their sleep including an in-depth review of psychological contributors to their insomnia, and then personalizing/customizing the approach.]
This study examined the effects of cognitive behavioural treatments for insomnia (CBT-I) and pain (CBT-P) in patients with comorbid fibromyalgia and insomnia. (Cognitive behavioral treatments for insomnia and pain in adults with comorbid chronic insomnia and fibromyalgia: clinical outcomes from the SPIN randomized controlled trial. McCrae CS1, Williams J2, Roditi D2, Anderson R2, Mundt JM2, Miller MB1, Curtis AF1, Waxenberg LB2, Staud R3, Berry RB4, Robinson ME2. Sleep. 2019 Mar 1;42(3). pii: zsy234. doi: 10.1093/sleep/zsy234, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424087/.)
Results showed that both treatments improved self-reported WASO, SE, and SQ. Effects were generally larger for CBT-I. DBAS only improved in CBT-I. Pain and mood improvements did not differ according to the group.
Other forms of CBT in the treatment of fibromyalgia
CBT-I is a specialized package for sleep. There are however other forms of CBT-I that may be useful in the treatment of fibromyalgia. Anxiety and depression are two of the most common symptoms of fibromyalgia. There are CBT treatments for each. The question arises as to whether there should be an attempt to offer CBT for each of these.
There has also been work showing benefit of CBT for catastrophization. In addition, the author has been trying to develop an approach for specialized CBT for nocturnal hypervigilance and light sleep in patients with fibromyalgia.
A study was done by Häuser et al. in 2015 to review the techniques, aims and efficacy of psychotherapeutic treatments of fibromyalgia. Results showed “robust evidence for the short and long-term efficacy of cognitive behavioral therapies on some key symptoms of FMS, e.g. pain, depression and disability.” They concluded as follows: Cognitive behavioral therapies (e.g. acceptance and commitment therapy, cognitive behavioral therapy and operant therapy) should play an important role in a graduated and individually tailored therapy of FMS patients.” ([Psychotherapeutic procedures for fibromyalgia syndrome] [Article in German], W Häuser 1, K Bernardy, DOI: 10.1007/s00393-014-1555-0, Z Rheumatol. 2015 Sep;74(7):584-90, abstract available online at: https://pubmed.ncbi.nlm.nih.gov/26334969/.)
CBT for catastrophic thoughts in fibromyalgia
“Cognitive therapy focuses on taking catastrophic thoughts and reframing them into more positive beliefs (Hassett and Gevirtz, 2009). Behavioral therapy, in contrast, stresses the importance of operant behavioral change over inner thoughts and feelings (Hassett and Gevirtz, 2009). Its goals are to increase adaptive behavior through positive and negative reinforcement, and to extinguish maladaptive behavior through punishment (Hassett and Gevirtz, 2009). Studies have demonstrated that both OBT and CBT are effective modalities in treating FM (Thieme et al., 2006; Thieme and Gracely, 2009). (Pharmacotherapy for Fibromyalgia, Howard S. Smith,1,* Donna Bracken,2 and Joshua M. Smith, Front Pharmacol. 2011; 2: 17 available in full online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131797/. This is an open-access article subject to a non-exclusive license between the authors and Frontiers Media SA, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and other Frontiers conditions are complied with.)
Neural substrate for improvements in the brain due to CBT in fibromyalgia
Lararidou et al. used CBT to great effect on a small study of fibromyalgia patients with proven beneficial impact on brain connectivity between two areas 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/.)
Their description of their technique is highly instructive. It could be used by others. It would also be reasonable to expand the focus from not only catastrophizing, but also to other areas of the psychology of fibromyalgia. This 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.
Treatment consisted of four sessions over one month. It involved structured techniques to alter distorted thoughts. The focus was on having the patient acquire and practice cognitive skills and emotion-regulation skills. The CBT utilized a pain-self management paradigm. It involved identification and subsequent reduction 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.”
Author’s opinion on the future of CBT in the treatment of fibromyalgia
As of 2020, the situation is shaping up in favor of using a combination of CBT treatments for fibromyalgia. CBT-I will likely be a cornerstone, but it will need to be modified to add new CBT interventions of nocturnal hypervigilance. In cases where specific issues such as catastrophization are playing a prominent role in driving systems, it seems logical to use and develop specific forms of CBT that target these issues.
CBT programs for an individual should be custom designed to address the key underlying drivers of that patient’s symptoms. This calls for a detailed assessment. This should include an attempt to clarify what is driving the patient’s symptoms. One tool for this which the author has found very helpful is his vortex questionnaire. It was designed to quantify the extent to which anxiety, pain and poor sleep all drive and interact with each other to increase the patient’s symptoms.
The author has also developed a tool to rate nocturnal hypervigilance. If a patient scores high, then it is logical to try a short course of customized CBT for hypervigilance which is herein designated as CBT-H.
CBT-I programs for anxiety are widely available and self-help workbooks exists.
Some patients have issues that are rare or unique to them but can be serious drivers of the fibromyalgia symptoms. They may require individualized psychotherapy of psychoanalysis for these issues.
For a very detailed review of psychological treatments of fibromyalgia including CBT see: Systematic Review of Psychological Treatment in Fibromyalgia, María José Lami, María Pilar Martínez & Ana Isabel Sánchez, (M Peres, Section Editor for fibromyalgia), Curr Pain Headache Rep. 2013 Jul;17(7):345.volume 17, article number: 345 (2013) https://doi.org/10.1007/s11916-013-0345-8, available in full online at: https://www.researchgate.net/publication/236958129_Systematic_Review_of_Psychological_Treatment_in_Fibromyalgia
For a respected practical book on the use of CBT-I in insomnia see: Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach Workbook. Jack D. Edinger, C. Carney, 2008
For information on the efficacy of CBT-I in the treatment of insomnia see: https://www.medscape.com/answers/1187829-70562/what-is-the-efficacy-of-cognitive-behavioral-therapy-cbt-for-insomnia.