Beyond cognitive-behavioral therapy for fibromyalgia: addressing stress by emotional exposure, processing, and resolution

I comment on the well-designed trial by Alda and colleagues reported in a recent issue of Arthritis Research and Therapy which demonstrated some benefits of cognitive-behavioral therapy (CBT) for fibromyalgia (FM). CBT in this and other studies provides statistically significant but rather modest benefits for FM. This may be because CBT does not directly address the high rates of victimization, post-traumatic stress disorder, and emotional avoidance experienced by a substantial number of patients with FM. Interventions that encourage emotional exposure, processing, and resolution of stressful or traumatic experiences and relationships hold potential for larger effects for many patients and need to be tested.

moderate-sized eff ects on overall FM impact and quality of life, small eff ects on depression and anxiety, and -of greatest concern -no eff ects on pain. Th ese results are generally consistent with recent meta-analyses [2,3], which report non-zero but rather modest benefi ts of CBT for FM. Overall, it appears that only a minority of FM patients -perhaps one-third -demon strate clinically meaningful improvement from CBT and other psychological/behavioral interventions [4].
Are small to moderate eff ects and a minority of patients improving the limit of eff ectiveness of psychological interventions for FM? Do genetics, long-term central nervous system sensitization, and socioeconomic contingencies simply 'account for more variance' and trump the infl uence of psychological processes? Perhaps, but I argue that we do not yet know, because our intervention eff orts have not been guided by the larger literatures on eff ective psychological therapies and pathological processes in FM.
I fi nd a tendency, especially in medical settings, to equate CBT with 'eff ective psychological therapy' and to contrast it with one alternative -'talk therapy' . Th is is incorrect. CBT is one of many psychological inter ventions that have proliferated over the past few decades, many of which are active, time-limited, and -most importantly -benefi cial. Furthermore, psycho therapy research has identifi ed general processes that predict positive outcomes across a range of psychological therapies. Five such processes are: a) providing a new rationale for the problem and how to change it; b) teaching symptom and self-management skills; c) experiencing and processing avoided emotions and memories; d) encouraging behaviors that have been avoided, usually due to negative emotions (for example, fear, guilt); and e) providing a supportive therapeutic relationship that also corrects faulty interpersonal expectations [5]. Th e primary focus of CBT for FM is providing the rationale of, and teaching cognitive and behavioral skills for, symptom management. CBT for pain typically does not Abstract I comment on the well-designed trial by Alda and colleagues reported in a recent issue of Arthritis Research and Therapy which demonstrated some benefi ts of cognitive-behavioral therapy (CBT) for fi bromyalgia (FM). CBT in this and other studies provides statistically signifi cant but rather modest benefi ts for FM. This may be because CBT does not directly address the high rates of victimization, posttraumatic stress disorder, and emotional avoidance experienced by a substantial number of patients with FM. Interventions that encourage emotional exposure, processing, and resolution of stressful or traumatic experiences and relationships hold potential for larger eff ects for many patients and need to be tested.
'open up' negative emotions, encourage previously avoided emotional experiences (except pain exposure exercises, which are probably helpful), or use the therapeutic relationship as a change vehicle.
How is this relevant to FM? Many studies have found elevated rates of trauma, victimization, and interpersonal confl ict among people with FM -at least among patients actively seeking treatment [6]. Such trauma and the subsequent avoidance of emotional processing lead to the increased post-traumatic stress disorder found in FM [7]. Suppressed and dysregulated anger, emotional unawareness and confusion, and reactivity to interpersonal confl ict are increased in FM. Th e elevated pain catastrophizing targeted by Alda and colleagues [1] encompasses rumination, helplessness, and somatic magnifi cationcommon consequences of unresolved stress.
Should we target for treatment the unresolved stress in patients with FM? If so, how? Interestingly, eff ective treatments for trauma and post-traumatic stress disorder, which encourage experiencing, expressing, and processing of stress-related emotional memories, remain largely untested for those FM patients who have victimization histories and emotional avoidance [8]. Th ere are a handful of small trials indicating the benefi ts to people with FM of private writing about stress, group therapy for enhancing emotional awareness, and individual therapy targeting unresolved stressors [9]. It is noteworthy that Alda and colleagues actually included two ancillary exercises that activate avoided emotionsexpressive writing and assertive communication. I applaud this, but encourage testing of interventions that have emotional processing as a primary target.
Perhaps we fear that patients will respond negatively to such an intervention -rejecting it, feeling stigmatized, and having increased symptoms. Such interventions also are emotionally challenging for therapists. We should not, however, let our fears prompt avoidance of potentially adaptive experiences. Colleagues and I are testing an intervention that has FM patients confront and process avoided emotional experiences and relationships, and are comparing it to CBT and an educational control. We do not yet know this intervention's eff ects, how it compares with CBT, and importantly -given the heterogeneity of FM -which patients benefi t most from each approach [10]. However, our initial observations are that almost all of our patients acknowledge that stress contributes to their FM symptoms, and patients fi nd that confronting avoided emotions immediately infl uences their pain, which powerfully demonstrates the relevance of their emotions. I encourage researchers, clinicians, and patients to be courageous and develop, test, and -if empirically supported -implement interventions that directly address the unresolved stressors experienced by many patients with FM.