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Try tailored psychotherapy for fibromyalgia.

PARIS -- Success rates for nonpharmacologic therapy in patients with fibromyalgia are climbing to previously unattainable levels by tailoring psychotherapy in accord with patient characteristics.

It is best to intervene before the physical and psychological impairments have hardened. Also, combining the tailored psychotherapy with an exercise training program seems to be important, mental health researchers said at the annual European Congress of Rheumatology.

Saskia van Koulil, Ph.D., summarized her recent comprehensive review of the published literature on nonpharmacologic therapies for fibromyalgia (Ann. Rheum. Dis. May 2007;66:571-81) as showing modest and inconsistent benefits. In many studies, 30% or less of treated patients had at least a 50% improvement in symptoms and functioning, and the benefits typically faded over 6 months or more of follow-up.

But this poor showing is probably attributable to a past tendency to take a one-size-fits-all approach to psychotherapy for what is in reality a quite heterogeneous syndrome, said Dr. van Koulil of Radboud University Nijmegen (the Netherlands).

She and her colleagues have developed a validated brief self-report screening instrument (Int. J. Behav. Med. March 2008; 15:211-20) to help differentiate the two major cognitive and behavioral patterns fibromyalgia patients exhibit: pain-avoidance behavior, which is an extension of the well-established psychological fear-avoidance model, and a pain-persistence pattern, in which patients ignore their pain and persist in painful activities to their detriment. The two patterns are equally common.

Fibromyalgia patients with a pain-avoidance pattern are more likely to benefit from operant-behavioral therapy focused on changing observable pain behaviors, while those with a predominantly pain-persistence pattern tend to fare better with cognitive-behavioral therapy addressing maladaptive thoughts. For patients who have elements of both patterns, either form of therapy appears to be appropriate, according to Dr. van Koulil.

She presented a randomized trial in which 216 fibromyalgia patients were assigned either to a multimodal intervention--including tailored psychotherapy--or to a usual-care control group. All had high levels of psychological distress as an inclusion criterion, in light of evidence that nonpharmacologic therapies are most effective in such patients.

The intervention consisted of small, 3-hour-long group sessions twice weekly for 8 weeks. Half of each session was devoted to tailored group psychotherapy, the other half to exercise training, which included pool exercise, aerobics, and relaxation therapy. The patient's significant other attended 3 sessions so therapists could address social reinforcement issues.

At the end of the intervention, patients rated its usefulness as 8.2 out of a possible 10. They also showed highly clinically relevant 80%-90% reductions on measures of pain, fatigue, functional disability, and anxiety

More important, at 6-month follow-up 57% of the multimodal intervention group maintained a clinically significant improvement as defined by at least a 0.5-standard deviation gain over baseline on physical functioning measures, compared with 29% of controls. And 49% in the intervention arm showed a similar improvement in psychological functioning, compared with 28% of controls.

Based upon these favorable results, the tailored nonpharmacologic intervention will be implemented nationally at the other Dutch university medical centers, Dr. van Koulil added.

Kati Thieme, Ph.D., reported on 125 fibromyalgia patients randomized to cognitive-behavioral therapy, operant-behavioral therapy, or a control group. Patients were followed for 12 months, at which point she and her colleagues looked retroactively at various pretreatment patient characteristics to see which ones separated subsequent responders from nonresponders.

The psychotherapy consisted of 15 once-weekly 2-hour sessions conducted in small groups codirected by a psychologist and a rheumatologist. The control group met on the same schedule for therapist-guided general discussions of the medical and emotional problems of fibromyalgia, with no therapist recommendations. Spouses attended 4 sessions. Patients were encouraged to increase their level of physical activity.

At 1 year follow-up, clinically meaningful improvements in pain intensity measures were documented in 54% of patients in the operant-behavioral therapy group, a statistically similar 45% of the cognitive-behavioral therapy group, and 5% of controls. In the operant-behavioral therapy group, 58% had significant reductions in physical impairment, as did 38% in the cognitive-behavioral therapy group and 7.5% of controls, according to Dr. Thieme of the University of Heidelberg (Germany).

In the cognitive-behavioral group, responders had higher baseline levels of affective distress and physical impairment than did nonresponders. Responders also displayed less-pronounced pain behaviors at baseline, lower coping ability, and less enabling behavior on the part of spouses.

Responders to operant-behavioral therapy had greater baseline physical impairment than nonresponders. Responders also had more mental catastrophizing, more pain behaviors, markedly more physician visits, and more solicitous spouse behaviors than nonresponders to cognitive-behavioral therapy.

Clinically significant deterioration in pain behaviors and physical impairment were reported by 48% of subjects in the control group, which implies that social discussion of fibromyalgia-relared problems in the absence of therapeutic intervention may be counterproductive, Dr. Thieme cautioned.

A prospective outcome study is warranted to confirm the hypothesis that tailoring therapy according to the patient characteristics identified in this trial actually results in better outcomes, she continued.

A noteworthy finding was the low attrition rate in both tailored-therapy studies. Clinical trials in fibromyalgia patients typically feature a very high dropout rate, regardless of whether they involve pharmacologic or nonpharmacologic treatments. But participants in the tailored-therapy trials were clearly engaged: The dropout rate in Dr. van Koulil's study was 5.5%. It was similar in the psychotherapy arms of Dr. Thieme's study, compared with 50% in the control group.

Her study was funded by the German Research Council.

Dr. van Koulifs was supported by the Dutch Arthritis Association.


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Title Annotation:Pain Medicine
Author:Jancin, Bruce
Publication:Clinical Psychiatry News
Date:Oct 1, 2008
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