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Fibromyalgia and Cognitive Behavioral Therapy

Dr. Dorothy McCoy (2002)

Recent findings have dispelled the belief that fibromyalgia is a psychosomatic disorder. It has a rather short history as a physical disorder, only achieving that status a mere 15 years ago.

Fibromyalgia is often foreshadowed by a physical and/or a psychologic trauma. For many years, much to the distress of its sufferers, fibromyalgia's etiology lay hidden in a mire of unanswered questions. Some researchers believe that disturbances in the "autonomic and endocrine stress response systems may underlie the etiology" of this agonizing condition (Millea, et al, 2001).

According to Millea and colleagues (2001), "fibromyalgia is a rheumatologic condition characterized by spontaneous, wide spread soft tissue pain, sleep disturbance, fatigue and extensively distributed areas of tenderness." Researchers are beginning to appreciate and analyze the complex relationship between the biochemical, physiological and psychological components of the disorder (Flemming, et al, 1997). Flemming and colleagues suggest that fibromyalgia is sympathetically maintained pain, which develops from an injury or illness. The illness or injury becomes "linked with the fight or flight mechanism, which is known as the sympathetic nervous system." It is not known how this relationship is established, however, once established the pain may become chronic. Normally, when an injury heals-- pain, our biological alarm system, no longer serves a beneficial purpose. Consequently, the resultant pain subsides. This normal progression to wellness does not happen in fibromyalgia. It is possible that chronic pain also has a benevolent objective. However, since we are currently ill equipped to decipher its message, chronic pain is considered a medical pain in the neck by physicians and suffers alike.

Co-morbid conditions

Fibromyalgia is often accompanied by "fatigue, headaches, irritable bowel syndrome, and insomnia" (Worrel, 2001). In addition, the more debilitating examples of fibromyalgia are frequently found in individuals with a history of depression.

According to Worrel, "Elevation of cerebrospinal fluid substance P levels (a neurotransmitter associated with enhanced pain perception) is found in a significant number of fibromyalgia cases." Other disorders, such as hypothyroidism and myofascial pain syndrome, can mimic fibromyalgia. Fortunately, hypothyroidism can be ruled out by a simple test.

Chronic Pain Management

Many management techniques are used to treat fibromyalgia. Treatments are often combined in a comprehensive treatment package to obtain the most relief for an individual patient. Some types of pain can be treated by "purely psychological means such as relaxation training or imagery exercise" (Fleming, et al, 1997). Guided imagery is used to help the patient relax, which facilitates healing. This technique is used in hundreds of hospitals around the country to treat various medical conditions. It is also commonly employed in psychotherapy settings, pain clinics and it is available on self-help tapes and CDs.

Anxiety and stress have a negative impact on fibromyalgia patients. Millea (2001) suggests that pain flare-ups can increase the patient's stress load; conversely, environmental stress can initiate a pain flare-up. Relaxation guided imagery is a powerful tool when employed to soothe patients and minimize their response to stress.
Health care providers need to hear their patients' stories about the challenges of living each day with a chronic pain disorder. Feeling heard and understood by their physician or therapist is an essential condition of an effective treatment. A chronic disorder necessitates a partnership in which the medical professional works with the patient to choose the most beneficial treatments. According to research this may include some non-pharmacological treatments such as Cognitive-Behavioral Therapy (CBT), relaxation techniques and massage. A recent study published in the Journal of the American Medical Association suggests that the treatments demonstrating the most promise for "patients with chronic fatigue were graded exercise and cognitive therapy" (Whiting 2001). Chronic fatigue is frequently a comorbid condition with fibromyalgia.

The Mayo Clinic uses a multidisciplinary treatment program, which includes psychotherapy to treat fibromyalgia. They employ a l½ day intensive schedule. It appears that even this very brief program improves symptoms in 70 percent of their patients (Worrel, BA et al, 2001).

In a recent study, CBT offered an alternative approach that demonstrated clinically significant improvement within six weeks (Edlinger, 2001). In another study, on chronic fatigue syndrome, the researchers compared standard treatment with cognitive therapy and standard treatment without cognitive therapy. "Seventy-three percent of the cognitive group were spending less time in bed and functioning normally after a year" (WebMD Health). Only 27% of the other group experienced the same gains. Flemming (1997) suggests amplifying standard treatments' efficacy by including bodywork and relaxation. According to the eminent wellness physician, Dr. Andrew Weil, guided imagery tapes are useful in reducing pain and speeding the healing process. In addition, something as simple and straightforward as an accurate diagnosis can legitimize the patient's experience. Patients are relieved to discover they have a legitimate medical disorder and the pain is not imaginary.

In a study on low back pain, researchers found that relaxation response training was effective in reducing pain severity. Twenty-eight of the patients also had fibromyalgia. Many of the study subjects reported reduced pain and a reduction in other symptoms, as well as "improved function and general health" (Millea, 2001). One panel of experts concluded that relaxation techniques were helpful in managing chronic pain. Furthermore, the techniques were valuable in managing the stress inherent in living with a chronic pain disorder. Yet anther study suggests that patients who believe they have little control over their symptoms report more severe and chronic fatigue. CBT is helping patients to change their inaccurate, self-defeating beliefs and regain a sense of control over their lives. A belief in one's ability to manage one's disorder frequently becomes a self-fulfilling prophecy.

CBT and relaxation therapy (a part of CBT) offer a non-pharmacological treatment option for treating chronic pain. In summary, according to the research studies, CBT and relaxation can be used to enhance one's coping ability, relieve pain, encourage restful sleep patterns, increase one's sense of control and well-being, reduce fatigue and improve general health. Cognitive-behavioral therapists can be found through CBT organizations such as the Association of Cognitive Behavioral Therapists at online.

Dr. Dorothy McCoy (2002)
Psychotherapist and author of self-help books, workbooks, CDs and e-courses on anxiety and other health issues. Website or