Is brief psychodynamic psychotherapy in primary fibromyalgia syndrome with concurrent depression an effective treatment? A randomized controlled trial

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

No effect of approved fibromyalgia drugs on the social pain (invalidation) contrary to physical pain: an open-label short-term randomized clinical trial

OBJECTIVES

The social pain or invalidation denoting painful feeling following social conflicts or misunderstanding about illness legitimacy has been proposed as a salient disabling symptom besides physical pain or non-pain symptoms in fibromyalgia (FM). We sought to evaluate the effect of 1-month administration of duloxetine or pregabalin on the invalidation dimensions in FM patients with respect to the comparison of these two drugs on this issue.

METHOD

This open-label randomized clinical trial study was performed on FM patients whose diagnoses were confirmed by a rheumatologist based on the 2016 American College of Rheumatology (ACR). Primary outcome measure (Illness Invalidation Inventory (3*I)) and secondary outcome measures (Beck Depression Inventory-II (BDI-II), widespread pain index (WPI), and polysymptomatic distress scale (PSD)) were compared before and after treatment, using paired t test or Wilcoxon signed test.

RESULTS

Of 81 eligible FM patients, 44 patients in the duloxetine arm and 27 patients in the pregabalin arm completed the study protocol. Overall, no significant improvement was seen in 3*I scores after treatment with either duloxetine or pregabalin, except in the lack of understanding of medical professionals which improved after treatment with pregabalin (2.43 ± 1.38 to 1.79 ± 0.94, p value: 0.01). There were no intragroup and intergroup differences in the effects of duloxetine and pregabalin on 3*I scores when adjusted with the cofounders. Both duloxetine and pregabalin improved WPI, BDI-II, and PSD scores significantly.

CONCLUSIONS

Short-term FM pharmacological treatment had no effect on social pain. This finding was regardless of drug type, improvement of physical pain, and depression.

The Effect of Psychological Interventions on the Quality of Life in Women with Fibromyalgia: A Systematic Review

Fibromyalgia refers to a painful type of rheumatological clinical syndrome, and its prevalence varies from 0.7% to 6.6%. This syndrome is associated with different physical and psychological symptoms, which ultimately leads to a decline in women's quality of life. A wide range of pharmacological and non-pharmacological interventions are conducted to mitigate these symptoms and improve the quality of life. Therefore, the present study aims to investigate the effect of psychological interventions on the quality of life in women with fibromyalgia. This systematic review with comprehensive search was carried out on Google Scholar, Scopus, PubMed, Web of Science, Science Direct, Cochrane Library, PsycINFO, and Scientific Information Database (SID), databases using the suitable keywords, and a total of 3125 articles from 2000 to 2019 were retrieved. Finally, the quality of 16 experimental and semi-experimental clinical trials was evaluated using the Jadad scale. The psychological interventions affecting the quality of life in women with fibromialgia included cognitive-behavioral therapy and behavioral therapy, coping strategies training, mindfulness, acceptance and commitment treatment, hypnosis, meditation, music therapy, short-term psychodynamic psychotherapy and writing emotions. The results of the study showed that except four studies, the studies generally improved the quality of life and reduced the symptoms in women with fibromyalgia. The results of the study suggest that most psychological interventions affect the quality of life in women with fibromyalgia. Therefore, besides pharmacological therapy, psychological interventions can be used by health-care providers to reduce the symptoms of fibromyalgia and improve the quality of their life.

Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects

OBJECTIVE

A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment.

METHODS

Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables.

RESULTS

We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = -1.07), which was maintained at long-term follow-up (SMD = -0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = -0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders.

CONCLUSIONS

STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.

Update Fibromyalgiesyndrom

In der neuen Klassifikation der Krankheiten (ICD-11) der Weltgesundheitsorganisation wurde das FMS – ohne Absprache mit rheumatologischen Fachgesellschaften – aus dem Kapitel „Erkrankungen des muskuloskelettalen System und des Bindegewebes“ entfernt und in ein neu geschaffenes Kapitel „Chronischer Schmerz“ aufgenommen. Pathologische Befunde an den kleinen Nervenfasern bei einer Untergruppe von Patienten belegen nicht, dass das FMS eine Neuropathie der kleinen Nervenfasern ist. Die Überprüfung der sogenannten Tender Points zur Diagnose des FMS ist nicht mehr erforderlich. Es wurden mehrere neue diagnostische Kriterien entwickelt, welche zur symptombasierten Diagnose neben chronischen Schmerzen in mehreren Körperregionen nicht-erholsamen Schlaf und Müdigkeit (körperlich und / oder geistig) erfordern. Die nach klinischen Kriterien durchführbare Schweregradeinteilung (leicht, mittel, schwer) des FMS ist wichtig für eine abgestufte Versorgung. In Abhängigkeit von psychologischen Befunden stehen verschiedene evidenzbasierte psychotherapeutische Verfahren zur Verfügung, welche bei schweren Formen des FMS eingesetzt werden sollen. Ein komorbides (sekundäres) FMS ist bei entzündlich-rheumatischen Erkrankungen häufig und führen zu falsch hohen Aktvitätsscores. Cannabisbasierte Arzneimittel sind eine Therapieoption für eine Untergruppe von FMS-Patienten.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.

OBJECTIVES

To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.

SELECTION CRITERIA

RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.

DATA COLLECTION AND ANALYSIS

Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.

MAIN RESULTS

We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.

AUTHORS' CONCLUSIONS

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.

Two sides on the fibromyalgia coin: physical pain and social pain (invalidation)

Although fibromyalgia (FM) has been traditionally defined by the extent of physical pain sites alongside other non-pain symptoms, recent evidence has highlighted the importance of social dimension in definition of pain perception. Social pain or invalidation, which denotes painful feeling following social conflicts or misunderstanding about illness legitimacy, is an important but ignored issue in the FM lexicon. While physical and social pain seem to be different and separate entities, we hypothesize that they are completely intertwined with indistinct borders in FM. Accumulating emergent neuroscience and behavioral evidence highlights the overlapping of physical and social pain in different painful conditions. However, this overlapping seems to reach its maximum in FM. This review sheds more light on the tight interconnectivity between physical and social pain in FM from the perspective of intuitional commonalities, clinical aspects, and shared neural pathways. The conceptualization of FM as an integrative physical-social pain paradigm will move us closer to necessitating the incorporation of social pain in future models of FM diagnosis and management. Key Points • Considering of social pain as one key concept is relatively mute in FM literature. • Overlapping of physical and social pain seems to be unique in FM due to its nature. • Acknowledging social pain in the FM lexicon could shift the paradigm of diagnosis and management of FM patients.

Group Psychotherapy With Fibromyalgia Patients: A Systematic Review

Objectives

This review aims to investigate the factors that play a role on the efficacy of group psychotherapy (GP) interventions for fibromyalgia syndrome (FMS).

Materials and methods

We employed a search using keywords group psychotherapy and fibromyalgia in the databases of Scopus, Web of Sciences, CINAHL, BMJ, MEDLINE, ScienceDirect and EBSCOhost.

Results

A total of 30 original studies were identified. These studies, which aimed to improve primary outcomes (POs-pain and fibromyalgia impact) and/or secondary outcomes (SOs-psychosocial), indicated that 15 were conducted in a multidisciplinary (MT) fashion, and the rest were unidimensional as they employed only GPs. Cognitive behavior therapy, which modifies dysfunctional thoughts and accompanying behaviors, was the most utilized psychological intervention. Overall, MTs were only slightly superior to GPs; however, improvements in POs were more frequent than SOs in MTs, and the vice versa in GPs.

Conclusion

Although studies varied in various methodological characteristics, the content of the interventions in MTs should be designed to cover the biopsychosocial nature of FMS.

Psychological therapies for chronic widespread pain and fibromyalgia syndrome

Psychological factors such as adverse childhood experiences, traumatic life events, interpersonal conflicts and psychological distress play an important role in the predisposition, onset and severity of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS). Therefore, psychological therapies might have the potential to reduce disability as well as symptom and economic burden in patients with CWP and FMS. Recent interdisciplinary guidelines have suggested different strengths of recommendation for psychological therapies for FMS. The aims of this narrative review are to summarise: • Mechanisms of actions. • Evidence on efficacy, tolerability and safety. • Knowledge gaps and needs for future research of psychological therapies for CWP and FMS for non-mental health professionals.

Facts and myths pertaining to fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread pain, unrefreshing sleep, physical exhaustion, and cognitive difficulties. It occurs in all populations throughout the world, with prevalence between 2% and 4% in general populations. Definition, pathogenesis, diagnosis, and treatment of FM remain points of contention, with some even contesting its existence. The various classification systems according to pain medicine, psychiatry, and neurology (pain disease; persistent somatoform pain disorder; masked depression; somatic symptom disorder; small fiber neuropathy; brain disease) mostly capture only some components of this complex and heterogeneous disorder. The diagnosis can be established in most cases by a general practitioner when the symptoms meet recognized criteria and a somatic disease sufficiently explaining the symptoms is excluded. Evidence-based interdisciplinary guidelines give a strong recommendation for aerobic exercise and cognitive behavioral therapies. Drug therapy is not mandatory. Only a minority of patients experience substantial symptom relief with duloxetine, milnacipran, and pregabalin.

Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial

Patients with fibromyalgia (FM) experience increased lifetime levels of psychosocial adversity, trauma, and emotional conflict. To address these risk factors, we developed emotion awareness and expression therapy (EAET) and tested its benefits against an active control condition, FM education, and the field's gold standard intervention for FM, cognitive behavioral therapy (CBT) for symptom management. Adults with FM (N = 230) formed 40 treatment groups, which were randomized to EAET, CBT, or education and given 8, 90-minute sessions. Patient-reported outcomes were assessed at baseline, posttreatment, and 6-month follow-up (primary end point). Retention of patients to follow-up was excellent (90.4%). Intent-to-treat analyses indicated that although EAET did not differ from FM education on pain severity (primary outcome), EAET had significantly better outcomes than FM education on overall symptoms, widespread pain, physical functioning, cognitive dysfunction, anxiety, depression, positive affect, and life satisfaction (between-condition d's ranging from 0.29-0.45 SD) and the percentage of patients reporting being "very much/much" improved (34.8% vs 15.4%). Emotional awareness and expression therapy did not differ from CBT on the primary or most secondary outcomes, but compared to CBT, EAET led to significantly lower FM symptoms (d = 0.35) and widespread pain (d = 0.37) and a higher percentage of patients achieving 50% pain reduction (22.5% vs 8.3%). In summary, an intervention targeting emotional awareness and expression related to psychosocial adversity and conflict was well received, more effective than a basic educational intervention, and had some advantages over CBT on pain. We conclude that EAET should be considered as an additional treatment option for FM.

The Cardiac Rehabilitation Psychodynamic Group Intervention (CR-PGI): An Explorative Study

Objective: An explorative study focusing on the process of a Cardiac Rehabilitation Psychodynamic Group Intervention (CR-PGI) addressed to myocardial infarction (MI) patients is discussed. The study aimed at analyzing whether the treatment based on CR-PGI serves as a communicational context within which MI patients are enabled to explore new interpretations of their post-infarction condition.

Methods: The intervention, divided into 12 weekly one-hour group sessions, was addressed to MI patients recruited within a Public Hospital of southern Italy. Each session was audio-recorded and lexical correspondence analysis (LCA) was applied to the verbatim transcripts, in order to provide a map of the evolution of the communication exchange occurring over the 12 sessions.

Results: The findings showed that the discourses associated to the first eight sessions differed from the discourses of the last four sessions. Two main transitions occurred. The first concerns the response to the infarction, first interpreted as a process of affective elaboration and afterwards as practical management of the functional aspects associated with the condition of MI patients. The second concerns the nature of the change and contrasts a lifestyle-oriented model with a social role approach, which refers to social, legal, and medical practices related to the acknowledgment of being an MI patient.

Conclusion: The findings offer preliminary support to the capacity of CR-PGI to work as a context where new meanings for the biographical rupture of the MI can be explored. Consistently with the rationale of the model, the intervention seems to have promoted the emergence of new ways of feeling and understanding one’s condition.

Effect of psychotherapy for depression on quality of life: meta-analysis

BACKGROUND

Several meta-analyses have shown that psychotherapy is effective for reducing depressive symptom severity. However, the impact on quality of life (QoL) is as yet unknown.

AIMS

To investigate the effectiveness of psychotherapy for depression on global QoL and on the mental health and physical health components of QoL.

METHOD

We conducted a meta-analysis of 44 randomised clinical trials comparing psychotherapy for adults experiencing clinical depression or elevated depressive symptoms with a control group. We used subgroup analyses to explore the influence of various study characteristics on the effectiveness of treatment.

RESULTS

We detected a small to moderate effect size (Hedges' g = 0.33, 95% CI 0.24-0.42) for global QoL, a moderate effect size for the mental health component (g = 0.42, 95% CI 0.33-0.51) and, after removing an outlier, a small but statistically significant effect size for the physical health component (g = 0.16, 95% CI 0.05-0.27). Multivariate meta-regression analyses showed that the effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component.

CONCLUSIONS

Psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.

Unresolved trauma in fibromyalgia: A cross-sectional study

This study examined the prevalence of unresolved attachment-related trauma and its association with physical and psychological health status in 34 patients with fibromyalgia. Unresolved trauma was assessed with the Adult Attachment Interview. In addition, participants completed self-report measures of childhood trauma, fibromyalgia-related health status and depression. Of the sample, 50 per cent was classified as unresolved on the Adult Attachment Interview. Neither interview-based ratings of unresolved trauma nor self-reported childhood sexual or physical abuse were associated with health outcomes. Only for self-reported emotional abuse, a positive correlation with depression emerged. The implications of the findings are discussed.

The effectiveness of psychodynamic psychotherapies: An update

This paper provides a comprehensive review of outcome studies and meta-analyses of effectiveness studies of psychodynamic therapy (PDT) for the major categories of mental disorders. Comparisons with inactive controls (waitlist, treatment as usual and placebo) generally but by no means invariably show PDT to be effective for depression, some anxiety disorders, eating disorders and somatic disorders. There is little evidence to support its implementation for post-traumatic stress disorder, obsessive-compulsive disorder, bulimia nervosa, cocaine dependence or psychosis. The strongest current evidence base supports relatively long-term psychodynamic treatment of some personality disorders, particularly borderline personality disorder. Comparisons with active treatments rarely identify PDT as superior to control interventions and studies are generally not appropriately designed to provide tests of statistical equivalence. Studies that demonstrate inferiority of PDT to alternatives exist, but are small in number and often questionable in design. Reviews of the field appear to be subject to allegiance effects. The present review recommends abandoning the inherently conservative strategy of comparing heterogeneous "families" of therapies for heterogeneous diagnostic groups. Instead, it advocates using the opportunities provided by bioscience and computational psychiatry to creatively explore and assess the value of protocol-directed combinations of specific treatment components to address the key problems of individual patients.

The efficacy of psychotherapy: focus on psychodynamic psychotherapy as an example

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.

Self-perspective leads to increased activation of pain processing brain regions in fibromyalgia

BACKGROUND

Dysfunction of central nervous pain processing is assumed to play a key role in primary fibromyalgia (FM) syndrome. This pilot study examined differences of pain processing associated with adopting different interpersonal perspectives.

METHODS

Eleven FM patients and 11 healthy controls (HC) were scanned with functional magnetic resonance imaging. Participants were trained to take either a self-perspective or another person's perspective when viewing the visual stimuli. Stimuli showed body parts in painful situations of varying intensity (low, medium, and high) and visually similar but neutral situations.

RESULTS

Patients with FM showed a higher increase in blood oxygen level dependent (BOLD) response, particularly in the supplementary motor area (SMA). All pain-related regions of interest (anterior insula, somatosensory cortices, anterior cingulate cortex, and SMA) showed stronger modulation of BOLD responses in FM patients in the self-perspective. In contrast to pain processing regions, perspective-related regions (e.g. temporoparietal junction) did not differ between FM and HC.

CONCLUSIONS

The stronger response of all four pain processing cerebral regions during self-perspective is discussed in the light of disturbed bottom-up processing. Furthermore, the results confirm earlier reports of augmented pain processing in FM, and provide evidence for sensitization of central nervous pain processing.

Mind and body therapy for fibromyalgia

BACKGROUND

Mind-body interventions are based on the holistic principle that mind, body and behaviour are all interconnected. Mind-body interventions incorporate strategies that are thought to improve psychological and physical well-being, aim to allow patients to take an active role in their treatment, and promote people's ability to cope. Mind-body interventions are widely used by people with fibromyalgia to help manage their symptoms and improve well-being. Examples of mind-body therapies include psychological therapies, biofeedback, mindfulness, movement therapies and relaxation strategies.

OBJECTIVES

To review the benefits and harms of mind-body therapies in comparison to standard care and attention placebo control groups for adults with fibromyalgia, post-intervention and at three and six month follow-up.

SEARCH METHODS

Electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), AMED (EBSCO) and CINAHL (Ovid) were conducted up to 30 October 2013. Searches of reference lists were conducted and authors in the field were contacted to identify additional relevant articles.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) of mind-body interventions for adults with fibromyalgia were included.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted the data and assessed trials for low, unclear or high risk of bias. Any discrepancy was resolved through discussion and consensus. Continuous outcomes were analysed using mean difference (MD) where the same outcome measure and scoring method was used and standardised mean difference (SMD) where different outcome measures were used. For binary data standard estimation of the risk ratio (RR) and its 95% confidence interval (CI) was used.

MAIN RESULTS

Seventy-four papers describing 61 trials were identified, with 4234 predominantly female participants. The nature of fibromyalgia varied from mild to severe across the study populations. Twenty-six studies were classified as having a low risk of bias for all domains assessed. The findings of mind-body therapies compared with usual care were prioritised.There is low quality evidence that in comparison to usual care controls psychological therapies have favourable effects on physical functioning (SMD -0.4, 95% CI -0.6 to -0.3, -7.5% absolute change, 2 point shift on a 0 to 100 scale), pain (SMD -0.3, 95% CI -0.5 to -0.2, -3.5% absolute change, 2 point shift on a 0 to 100 scale) and mood (SMD -0.5, 95% CI -0.6 to -0.3, -4.8% absolute change, 3 point shift on a 20 to 80 scale). There is very low quality evidence of more withdrawals in the psychological therapy group in comparison to usual care controls (RR 1.38, 95% CI 1.12 to 1.69, 6% absolute risk difference). There is lack of evidence of a difference between the number of adverse events in the psychological therapy and control groups (RR 0.38, 95% CI 0.06 to 2.50, 4% absolute risk difference).There was very low quality evidence that biofeedback in comparison to usual care controls had an effect on physical functioning (SMD -0.1, 95% CI -0.4 to 0.3, -1.2% absolute change, 1 point shift on a 0 to 100 scale), pain (SMD -2.6, 95% CI -91.3 to 86.1, -2.6% absolute change) and mood (SMD 0.1, 95% CI -0.3 to 0.5, 1.9% absolute change, less than 1 point shift on a 0 to 90 scale) post-intervention. In view of the quality of evidence we cannot be certain that biofeedback has a little or no effect on these outcomes. There was very low quality evidence that biofeedback led to more withdrawals from the study (RR 4.08, 95% CI 1.43 to 11.62, 20% absolute risk difference). No adverse events were reported.There was no advantage observed for mindfulness in comparison to usual care for physical functioning (SMD -0.3, 95% CI -0.6 to 0.1, -4.8% absolute change, 4 point shift on a scale 0 to 100), pain (SMD -0.1, CI -0.4 to 0.3, -1.3% absolute change, less than 1 point shift on a 0 to 10 scale), mood (SMD -0.2, 95% CI -0.5 to 0.0, -3.7% absolute change, 2 point shift on a 20 to 80 scale) or withdrawals (RR 1.07, 95% CI 0.67 to 1.72, 2% absolute risk difference) between the two groups post-intervention. However, the quality of the evidence was very low for pain and moderate for mood and number of withdrawals. No studies reported any adverse events.Very low quality evidence revealed that movement therapies in comparison to usual care controls improved pain (MD -2.3, CI -4.2 to -0.4, -23% absolute change) and mood (MD -9.8, 95% CI -18.5 to -1.2, -16.4% absolute change) post-intervention. There was no advantage for physical functioning (SMD -0.2, 95% CI -0.5 to 0.2, -3.4% absolute change, 2 point shift on a 0 to 100 scale), participant withdrawals (RR 1.95, 95% CI 1.13 to 3.38, 11% absolute difference) or adverse events (RR 4.62, 95% CI 0.23 to 93.92, 4% absolute risk difference) between the two groups, however rare adverse events may include worsening of pain.Low quality evidence revealed that relaxation based therapies in comparison to usual care controls showed an advantage for physical functioning (MD -8.3, 95% CI -10.1 to -6.5, -10.4% absolute change) and pain (SMD -1.0, 95% CI -1.6 to -0.5, -3.5% absolute change, 2 point shift on a 0 to 78 scale) but not for mood (SMD -4.4, CI -14.5 to 5.6, -7.4% absolute change) post-intervention. There was no difference between the groups for number of withdrawals (RR 4.40, 95% CI 0.59 to 33.07, 31% absolute risk difference) and no adverse events were reported.

AUTHORS' CONCLUSIONS

Psychological interventions therapies may be effective in improving physical functioning, pain and low mood for adults with fibromyalgia in comparison to usual care controls but the quality of the evidence is low. Further research on the outcomes of therapies is needed to determine if positive effects identified post-intervention are sustained. The effectiveness of biofeedback, mindfulness, movement therapies and relaxation based therapies remains unclear as the quality of the evidence was very low or low. The small number of trials and inconsistency in the use of outcome measures across the trials restricted the analysis.

Short-term psychodynamic psychotherapies for common mental disorders

BACKGROUND

Since the mid-1970s, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Early published meta-analyses of STPP, using different methods and samples, have yielded conflicting results, although some meta-analyses have consistently supported an empirical basis for STPP. This is an update of a review that was last updated in 2006.

OBJECTIVES

To evaluate the efficacy of STPP for adults with common mental disorders compared with wait-list controls, treatments as usual and minimal contact controls in randomised controlled trials (RCTs). To specify the differential effects of STPP for people with different disorders (e.g. depressive disorders, anxiety disorders, somatoform disorders, mixed disorders and personality disorder) and treatment characteristics (e.g. manualised versus non-manualised therapies).

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) was searched to February 2014, this register includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, DARE and Biological Abstracts (all years to July 2012) and all relevant studies (identified to 2012) were fully incorporated in this review update. We checked references from papers retrieved. We contacted a large group of psychodynamic researchers in an attempt to find new studies.

SELECTION CRITERIA

We included all RCTs of adults with common mental disorders, in which a brief psychodynamic therapy lasting 40 or fewer hours in total was provided in individual format.

DATA COLLECTION AND ANALYSIS

Eight review authors working in pairs evaluated studies. We selected studies only if pairs of review authors agreed that the studies met inclusion criteria. We consulted a third review author if two review authors could not reach consensus. Two review authors collected data and entered it into Review Manager software. Two review authors assessed and scored risk of bias. We assessed publication bias using a funnel plot. Two review authors conducted and reviewed subgroup analyses.

MAIN RESULTS

We included 33 studies of STPP involving 2173 randomised participants with common mental disorders. Studies were of diverse conditions in which problems with emotional regulation were purported to play a causative role albeit through a range of symptom presentations. These studies evaluated STPP for this review's primary outcomes (general, somatic, anxiety and depressive symptom reduction), as well as interpersonal problems and social adjustment. Except for somatic measures in the short-term, all outcome categories suggested significantly greater improvement in the treatment versus the control groups in the short-term and medium-term. Effect sizes increased in long-term follow-up, but some of these effects did not reach statistical significance. A relatively small number of studies (N < 20) contributed data for the outcome categories. There was also significant heterogeneity between studies in most categories, possibly due to observed differences between manualised versus non-manualised treatments, short versus longer treatments, studies with observer-rated versus self report outcomes, and studies employing different treatment models.

AUTHORS' CONCLUSIONS

There has been further study of STPP and it continues to show promise, with modest to large gains for a wide variety of people. However, given the limited data, loss of significance in some measures at long-term follow-up and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.

[Fibromyalgia syndrome as a psychosomatic disorder - diagnosis and therapy according to current evidence-based guidelines]

OBJECTIVES

The classification and therapy of patients with chronic widespread pain without evidence of somatic factors as an explanation is currently a matter of debate. The diagnostic label "fibromyalgia syndrome"(FMS) has been rejected by some representatives of general and psychosomatic medicine.

METHODS

A summary is given of the main recommendations from current evidence-based guidelines on FMS and nonspecific/functional/somatoform bodily complaints.

RESULTS

The criteria of FMS and of persistent somatoform pain disorder or chronic pain disorder with somatic and psychological factors partly overlap. They include differential clinical characteristics of persons with chronic widespread pain but without sufficiently explaining somatic factors. Not all patients diagnosed with FMS meet the criteria of a persistent somatoform pain disorder. FMS is a functional disorder, in which in most patients psychosocial factors play an important role in both the etiology and course of illness. FMS can be diagnosed by looking at the history of a typical symptom cluster and excluding somatic differential diagnoses (without a tender point examination) using the modified 2010 diagnostic criteria of the American College of Rheumatology. Various levels of severity of FMS can be distinguished from a psychosomatic point of view, ranging from slight (single functional syndrome) to severe (meeting the criteria of multiple functional syndromes) forms of chronic pain disorder with somatic and psychological factors, of persistent somatoform pain disorder or of a somatization disorder. The diagnosis of FMS as a functional syndrome/stress-associated disorder should be explicitly communicated to the patient. A therapy within collaborative care adapted to the severity should be provided. For long-term management, nonpharmacological therapies such as aerobic exercise are recommended. In more severe cases, psychotherapy of comorbid mental disorders should be conducted.

CONCLUSIONS

The coordinated recommendations of both guidelines can synthesize general medical, somatic, and psychosocial perspectives, and can promote graduated care of patients diagnosed with FMS.