CBT Reduces Pain Catastrophizing Post-Treatment in Fibromyalgia

Cognitive behavioral therapy (CBT) produced clinical benefits in patients with fibromyalgia by reducing pain-related catastrophizing and inducing adaptive alterations in default mode network functional connectivity, according to a study published in Arthritis and Rheumatology.¹ Results indicated clinically significant and CBT-specific links between the default mode network in chronic pain and somatosensory/motor- and salience-processing brain regions.

“In this study, we looked at the interplay between psychological processes and the brain's connectivity patterns in response to pain,” said co-lead investigator Robert Edwards, PhD, a clinical psychologist in the department of Anesthesiology, Perioperative and Pain Medicine at Brigham and Women’s Hospital. “We wanted to explore how CBT, a talk therapy aimed at combatting maladaptive thoughts, can enhance individuals’ daily functioning and alter the brain’s processing of pain-related information.”

Although fibromyalgia is often a difficult condition to treat, previous research has shown non-pharmacologic interventions, such as CBT, can reduce emotional distress, pain, and disability among this patient population. CBT works by altering distorted thoughts using structured techniques designed to reduce the pain-catastrophizing commonly presented in this patient population.² These strategies focused on identifying and assessing negative thoughts and patients learned to use cognitive restructuring to reduce distress.

In this randomized, controlled, mechanistic trial, investigators initially enrolled 114 adult women with fibromyalgia, of which 98 were given a baseline neuroimaging evaluation and participated in 8 weeks of either individual CBT or a fibromyalgia education control condition (EDU). The primary endpoint was the Pain Interference subscale of the Brief Pain Inventory (BPI). Additional endpoints were the Fibromyalgia Impact Questionnaire-Revised (FIQR), BPI Pain Severity, and the Pain Catastrophizing Scale (PCS).

Differences between groups at baseline included higher BPI scores in the CBT cohort compared with the EDU cohort (P <.05), although patients were comparable in terms of expectations for pain relief.

Those receiving CBT experienced significant improvements in pain interference, as measured by BPI scores. Additionally, patients in the CBT cohort reported larger decreases in pain catastrophizing post-treatment when compared with the EDU cohort (P <.05), as well as larger reductions in the impact of symptoms. These reductions were shown to mediate functional improvement in these patients. FIQR scores were also significantly reduced post-treatment in the CBT group compared with the EDU group.

Brain functional connectivity between the ventral posterior cingulate cortex (vPCC) and somotomotor and salience network regions was increased at baseline when patients experienced catastrophizing thoughts. However, after receiving CBT, vPCC connectivity to somatomotor and salience network areas was reduced.

Investigators noted the sample size, the validated in-scanner task, and the matched education control group as strengths of the study. However, enrolling only female patients was considered a limitation. Additionally, researchers were unable to fully determine which CBT skills were the most beneficial in reducing catastrophizing and differences in baseline values may have hindered the interpretation of results. They encouraged future research to include long-term, post-treatment neuroimaging evaluations to assess the stability of functional connectivity changes.

“Prior to participants undergoing CBT, we saw that certain parts of the brain linked to self-awareness and sensation were very connected, suggesting patients were pertinently aware of the pain sensation they were experiencing and internalized these symptoms,” concluded co-lead investigator Jeungchan Lee, PhD, an instructor in the department of Physical Medicine and Rehabilitation based at the Spaulding Rehabilitation Hospital and the Athinoula A Martinos Center for Biomedical Imaging at Massachusetts General Hospital. “After CBT, these connections were significantly less strong, suggesting that patients were better at separating themselves from their pain after therapy.”

References

1. ^{Lee J, Lazaridou A, Paschali M, et al. A Randomized, Controlled Neuroimaging Trial of Cognitive-Behavioral Therapy for Fibromyalgia Pain [published online ahead of print, 2023 Sep 20]. Arthritis Rheumatol. 2023;10.1002/art.42672. doi:10.1002/art.42672}
2. ^{Driscoll MA, Edwards RR, Becker WC, Kaptchuk TJ, Kerns RD. Psychological interventions for the treatment of chronic pain in adults. Psychol Sci Public Interest 2021;22:52-95.}