Cognitive Therapy and Research

, Volume 37, Issue 5, pp 1015–1026

Effectiveness of Mindfulness-Based Cognitive Therapy in the Treatment of Fibromyalgia: A Randomised Trial

  • Marta Parra-Delgado
  • José Miguel Latorre-Postigo
Original Article

DOI: 10.1007/s10608-013-9538-z

Cite this article as:
Parra-Delgado, M. & Latorre-Postigo, J.M. Cogn Ther Res (2013) 37: 1015. doi:10.1007/s10608-013-9538-z

Abstract

Fibromyalgia syndrome has a strong clinical and social impact affecting the personal, family and working life of the sufferer. The presence of depressive symptoms is associated with decreased quality of life and an increase in the intensity of pain. The aim of this study is to demonstrate the effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) in reducing the impact of fibromyalgia, the depressive symptoms and the intensity of pain in women with fibromyalgia. An experimental pre-post treatment design with a 3-month follow-up was carried out. Female patients (N = 33) were randomised to MBCT or to a control group condition. MBCT is an 8-week group intervention. Measures included: Fibromyalgia Impact Questionnaire, Beck Depression Inventory and Visual Analogue Scale. Substantial differences were found in the reduction of the impact of fibromyalgia after treatment and in the decrease in depressive symptoms decrease in the follow-up. A slight decrease was observed in intensity of pain in different body areas although there were no significant differences between the groups. The study findings suggest that depressive symptoms and the impact of the illness were reduced in the MBCT group of women diagnosed with fibromyalgia. These changes were maintained during the 3-month follow up. No significant changes were found in the reduction of intensity of pain. The limitations of this study were analysed and possible improvements for future research were considered.

Keywords

Mindfulness-based cognitive therapy Fibromyalgia Depression Pain 

Introduction

Fibromyalgia syndrome is characterised by widespread chronic musculoskeletal pain with different clinical, physical and psychological symptoms. The etiology is undetermined although various biological, genetic and environmental factors are thought to be involved in the appearance and development of fibromyalgia (Geoffroy et al. 2012). The estimated prevalence in different industrialised countries in the general population is 0.7–4.7 % (Branco et al. 2010; Eich et al. 2008). The prevalence is significantly higher in women than in men with the overall female-to-male ratio of 9–1 (Bartels et al. 2009; Yunus 2002). The diversity of symptoms of fibromyalgia causes sufferers to have major problems adapting their life, family and working environments (Bernard et al. 2000; Neumann and Buskila 1997; Reisine et al. 2003; Söderberg et al. 1999). It is also associated with a high rate of consultation and increased use of health and social resources (Sicras-Mainar et al. 2009; Tornero et al. 2002; Wolfe et al. 1997).

The cognitive and psychological symptoms are considered a major problem by 50 % of patients with fibromyalgia (Wilson et al. 2009). Depression and anxiety symptoms are more common in patients with fibromyalgia than in the general population (Epstein et al. 1999; Raphael et al. 2006; Thieme et al. 2004; Wolfe et al. 1995). The presence of these symptoms is related to a higher level of inappropriate response to stress, more severe fibromyalgia syndrome and a greater consumption of economic resources (Aparicio et al. 2011). A number of studies indicate that major depressive disorder has highest psychiatric comorbidity in patients with fibromyalgia with a prevalence ranging from 20 to 80 % (Aguglia et al. 2011; Fietta et al. 2007). In addition, Aguglia et al. (2011) found that 83.3 % of patients showed clinically significant depressive symptoms. The severity of depression correlates significantly with the severity of the fibromyalgia syndrome (Alok et al. 2011; Vishne et al. 2008). The presence of depressive symptomology is associated with an increase in the perception of pain and reduced quality of life in sufferers of fibromyalgia (Aguglia et al. 2011; González et al. 2010; Hoffman and Dukes 2008).

Recent studies recommend multimodal treatment based on light physical exercise, cognitive behavioural therapy, patient education, biofeedback relaxation and medication (Burckhardt 2006; de Miquel et al. 2010; Glombiewski et al. 2010; Thieme et al. 2008). However, there is a clear need for continued research into both the diagnosis and classification of fibromyalgia syndrome and the therapeutic approach to FMS (Geoffroy et al. 2012; Giesecke et al. 2003; Häuser et al. 2010; Thieme and Gracely 2009; Wierwille 2012; Wolfe et al. 2010).

It has been observed that acceptance is a cognitive variable which is beneficial to patients with chronic disease as it has a long-term adaptive function in physical and psychological wellbeing (Evers et al. 2001). A greater acceptance of pain is associated with lower pain intensity, less anxiety and depression, increased daily activity and a lower intake of medication (McCracken 1998; McCracken and Eccleston 2005). However, women with fibromyalgia and depression symptoms present an increased use of emotional avoidance strategies and a reduction in positive emotions (Brosschot and Aarsse 2001; van Middendorp et al. 2008).

Third generation therapies (Hayes 2004; Baer 2006) can provide fibromyalgia patients strategies and practical skills which allow them to accept adverse internal experiences and to be in contact with the present moment. Mindfulness means being fully aware of your inner experience in the present moment and accepting it with a non-judgmental and non-evaluative approach (Raes and Williams 2010). Scientific evidence suggests that the practice of mindfulness can be a protective factor in the development of psychopathological symptoms and the improvement of physical and mental health (Gilbert and Christopher 2010; Marchand 2012). Current systematic reviews (Chiesa and Serretti 2010, 2011; Fjorback et al. 2011; Hofmann et al. 2010) on mindfulness-based interventions demonstrate the effectiveness of Mindfulness-Based Stress Reduction Therapy (MBSR; Kabat-Zinn 1982, 1990) and Mindfulness-Based Cognitive Therapy (MBCT; Segal et al. 2002) in the improvement of mental health, reduction of symptoms of stress, anxiety and depression, coping with chronic health problems and the prevention of recurrent episodes in sufferers of depression. Mindfulness moderates the relationship between pain intensity and pain catastrophizing with possibly important clinical implications (Schütze et al. 2010).

MBCT is a group intervention that integrates mindfulness mediation training and cognitive restructuring techniques (Beck et al. 1979; Ellis 1962). It was developed to target depressive relapse in those vulnerable to episodes of depression. This approach allows participants to relate differently to thoughts, feelings and body sensations with an attitude of letting things be as they are, with kindness towards the experience of the present moment and acceptance of difficulties (Teasdale et al. 1995). The therapy has proved to be effective in the reduction of depression relapse in patients who have experienced three or more depressive episodes in the past, in the decrease of the residual symptoms of depression and anxiety and in the improvement of the quality of life of these patients (Coelho et al. 2007; Geschwind et al. 2012; Ma and Teasdale 2004; Michalak et al. 2008; Miró et al. 2011). Studies have confirmed the increase of mindfulness skills and the reduction of rumination and worry in recurrent depressed patients with and without a current depressive episode (van Aalderen et al. 2012). It has been established that MBCT improves symptoms of depression and anxiety, perception of quality of life and distress in patients with chronic health problems such as cancer or Parkinson’s disease (Fitzpatrick et al. 2010; Foley et al. 2010).

Scientific evidence on the effectiveness of MBCT in significantly reducing depression symptoms and of MBSR in reducing different symptoms suffered by patients with chronic health problems, including fibromyalgia (Lush et al. 2009; Merkes 2010; Rosenzweig et al. 2010; Sephton et al. 2007), makes it interesting to examine the effectiveness of MBCT in the treatment of fibromyalgia syndrome. To our knowledge, no research exists on the use of these programmes in symptoms of depression and pain in patients diagnosed with fibromyalgia. Parra et al. (2012) have found a significant reduction of state anxiety symptoms after MBCT although this improvement is not maintained in the 3 months follow-up.

The main objective of the present study was to examine whether MBCT is successful in reducing the impact of the illness, as well as the depressive symptoms and the pain perceived in different parts of the body in fibromyalgia patients.

Method

Design

A randomised experimental design was conducted with three repeated measures (pre-test, post-test and 3-month follow-up). The participants were randomly assigned either to experimental group (MBCT) or to treatment as usual control group (CG).

Participants

A total of 45 women from the Fibromyalgia Association of Almansa, Spain (AFIBROAL) participated in the research voluntarily. In order to take part in the study the participants had to meet two inclusion criteria: (a) being diagnosed with fibromyalgia syndrome in accordance with the diagnostic criteria proposed by the AmericanCollegeofRheumatology (Wolfe et al. 1990) and (b) committing to the daily practice of mindfulness. Two exclusion criteria were also established: (a) being diagnosed with alcohol and/or substance dependence and/or abuse and (b) receiving psychological therapy from the Castilla-La Mancha Health Service fibromyalgia team. Regarding the first inclusion criteria, the participants’ fibromyalgia diagnosis was confirmed by staff of the multidisciplinary team of the chronic and musculoskeletal pain of the Albacete University Hospital.

The 33 participants who met the proposed criteria were randomly assigned to the MBCT intervention single group (n = 17) or the treatment as usual control group (CG) (n = 16) using the Random Number Generator programme (Devilly 2004a). The therapy was completed by 15 of the 17 patients. The dropout rate in the MBCT group was 11.76 % if we consider experimental mortality to be failure to attend at least 4 of the 8 MBCT sessions. The dropout rate in the control group was 0 %. Participant flow is displayed below (Fig. 1).
Fig. 1

Participant flow diagram. MBCT mindfulness based cognitive therapy, CG treatment as usual control group condition

The 33 participants were aged between 30 and 77 (M = 52.67, SD = 10.08). 75.8 % were married, 63.6 % had completed primary education, 57.6 % were homemakers and 18.2 % were on leave for temporary incapacity. The participants reported suffering from the syndrome for between 2 and 60 years (M = 21.27, SD = 15.22). 63.3 % of the participants presented a major depressive episode, 39.4 % recurrent major depressive episodes, 15.2 % a panic disorder without agoraphobia, 30.3 % a panic disorder with agoraphobia, 9.1 % agoraphobia without a history of panic disorder and 9.1 % presented no psychiatric disorder. 30.3 % presented comorbidity between depression and anxiety disorders. 36.4 % of the patients were taking antidepressants, 18.2 % anxiolytics and 21.2 % both types of medication.

Measures

Interview for patients with chronic pain (Miró 2003). The interview collects clinical information and other information on different aspects of the patient’s life. The average duration of the interview is 1 h 30 min.

MiniInternationalNeuropsychiatricInterview (MINI; Sheehan et al. 1997) (Spanish version 5.0.0 adapted by Ferrando et al. 1997). The MINI is a short, diagnostic, structured interview of approximately 15 min which explores the principal Axis 1 mental disorders from the DSM-IV classification (APA 1994) and the ICD-10 (International Classification of Diseases, 1992). The modules were completed allowing diagnosis of the decisive clinical categories for exclusion of candidates for the trial. The modules used were: A. Major Depressive Episode, B. Major Depressive Episode, Recurrent C. Risk for suicide, E. Panic Disorder, F. Agoraphobia, J. Alcohol-Related Disorders, K. Substance-Induced Disorders. Comparing the MINI with the Structured Clinical Interview for DSM-III-R Patients (SCID-P; Spitzer et al. 1990), the results show that the MINI has a high level of validity and reliability (Sheehan et al. 1997).

Fibromyalgia Impact Questionnaire (FIQ; Burckhardt et al. 1991) (Spanish version adapted by Rivera and González 2004). The FIQ is used to quantify the level of dysfunction caused in the patient by the symptoms of fibromyalgia in the last 7 days. The FIQ is an easily administered, short (5 min), multidimensional questionnaire which is commonly used. It comprises 10 questions corresponding to 10 scales: physical functioning, feel good, days of work, hard at work, pain, fatigue, morning tiredness, stiffness, anxiety and depression. Each scale has a maximum score of 10. The overall impact fluctuates between 0 and 100 and is obtained by summing the scores in the ten scales described. Higher scores indicate greater impact of fibromyalgia on functioning. The average score in fibromyalgia patients is 50 and in severely affected patients is about 70 (Bennett 2005). The Spanish version of the FIQ has shown good psychometric properties (Rivera and González 2004), in the same way as the original questionnaire (Bennett 2005).

Beck Depression Inventory (BDI; Beck et al. 1979) (Spanish version adapted by Sanz and Vazquez 1998a). The BDI consists of 21 items. The direct total score varies from 0 to 63 points. The cut-off points used are: minimal depression (0–9 points), mild depression (10–18 points), moderate depression (19–29 points) and severe depression (30–63 points). The agreed cut-off point for differentiating between depressive and non-depressive patients is 18 points (Rudd and Rajab 1995; Sanz and Vázquez 1998b). The indices of reliability and validity of the Spanish version are high (Sanz and Vázquez 1998b).

VisualAnalogue Scale (VAS; Huskisson 1974) (validated in Spanish by González et al. 1995). The VAS provides an objective pain score “on the day” in different areas of the body. It scores from 0 to 10, where 0 represents “no pain” and 10 “maximum pain”. It is one of the most commonly used scales (Serrano-Atero et al. 2002) and shows acceptable indices of reliability and validity (González et al. 1995).

Procedure

The 45 people interested in taking part in the research attended an initial interview in which their socio-demographic and clinical data were collected. The 33 women who met the inclusion and exclusion criteria were called to complete the different questionnaires. Following the recommendations of Segal et al. (2002), the experimental single group participated in MBCT for 3 months, comprising eight structured group sessions each lasting 2 h 30 min. Intervention is considered complete if more than four of the eight sessions are attended (Segal et al. 2002). The treatment was completed by 88.2 % of the participants of which 5.9 % attended four sessions, 23.5 % five, 29.4 % six, 17.6 % seven and 11.8 % eight sessions. In general, 58.8 % attended six or more of the eight sessions (M = 5.53, DT = 1.87). All the participants continued with their usual medication treatment, medical visits, rehabilitation sessions and the activities proposed by the Fibromyalgia Association. The sessions were administered by a therapist with practical and theoretical certified training in MBCT. Different practical mindfulness exercises were conducted at each of the sessions, with special focus on pain-related stimuli. The main aim was for patients to learn mindfulness techniques in order to relate to their experience of pain and the thoughts and feelings it provokes in a different way, responding in a compassionate and non-judgemental way The participants were invited to reflect on the transitory nature of the different painful stimuli and were invited to experience their thoughts as passing events of the mind rather than absolute truths. Psycho-educational activities on the causes and development of the symptoms of depression and anxiety were also conducted. In the final sessions the participants were invited to identify simple methods of self-care and to use the skills learnt to respond to future mood states and/or painful body experiences. During therapy the participants carried out formal practice at home (i.e., body scan, sitting meditation, walking meditation or mindful breathing) 6 days a week. The sessions began with feedback on the practice conducted at home and ended with the assignment of tasks to be done at home and written summaries of each session.

The modifications to the MBCT for the women with fibromyalgia were: a closer look at the acceptance of the experience of pain in the different meditation practices of mindfulness, encouraging participants to be aware of the automatic thoughts related to the response to pain and their relationship to the feelings and behaviours it caused, providing information on anxiety and its causes (requested by the patients), explaining the importance of not forcing their body into yoga postures and of feeling comfortable by using appropriate clothes and postures, during the practice of mindfulness.

At the end of the present study, those participants of the control group who did not meet inclusion criteria were invited to complete MBCT.

Statistical Analysis

The normality of the study variables was tested with a Shapiro–Wilk test. The variables measuring the intensity of pain did not meet the assumption of normality so were transformed following the recommendations of Maxwell and Delaney (2004). A one-way ANOVA was used to determine whether significant differences existed between MBCT and CG. The paired-sample t test was used to examine intra-group change. The percentage of change between the pre-test and the post-test and between the pre-test and the follow-up of each of the groups, as was Cohen’s d effect size, where 0.2 is indicative of a small effect, 0.5 a medium and 0.8 a large effect size (Cohen 1992). A 2 × 3 ANOVA with an inter-subject independent variable with two levels (experimental and control) and with time (pre-test, pot-test and follow-up) as intra-subject independent variable was used in order to find the main effects and the interaction of the independent variables (group and time) on the dependent variable to be studied,. In the case of the FIQ variable, since significant differences existed in the pre-test an ANCOVA was run with the value of the FIQ variable in the pre-test as covariate. The analyses were conducted with a confidence interval of 95 % using SPSS for Windows v. 17.0, Sample Power 2.0 for Windows (Borenstein et al. 2001) and ‘The Effect Size Generator for Windows: Version 2.3’ (Devilly 2004b).

Results

Descriptive Statistics

A study of the homogeneity of the two groups in the socio-demographic and clinical variables found no significant differences (Table 1).
Table 1

Sociodemographic and clinical variables of MBCT and CG

Variables

MBCT

(n = 15)

CG

(n = 16)

Differences test

p

Age M (SD)

53.13 (10.50)

52.69 (10.58)

t = −.11

.90

Educational level

 No school completed

33.3 % (5)

25 % (4)

U = 106

.52

 Primary

60 % (9)

62.5 % (10)

  

 Secondary/University

6.6 % (1)

12.5 % (2)

  

Employment status

 Employed

0 % (0)

37.5 % (6)

FLevene = 2.56

.12

 Homework

73.3 % (11)

50 % (8)

  

 On leave/disability

26.6 % (4)

12.5 % (2)

  

 Years since syndrome onset M (SD)

21.7 (16.64)

22.5 (13.84)

t = .17

.86

Factors that worsen symptoms

 Physical

6.6 % (1)

12.5 % (2)

χ2 = 1.59

.45

 Emotional

40 % (6)

56.2 % (9)

  

 Both

53.3 % (8)

31.2 % (5)

  

Use of medication

 Neither

20 % (3)

25 % (4)

χ2 = 1.11

.77

 Antidepressants

33.3 % (5)

43.7 % (7)

  

 Anxiolytics

20 % (3)

18.7 % (3)

  

 Both

26.6 % (4)

12.5 % (2)

  

Expectations of results

 Few

13.3 % (2)

31.2 % (5)

χ2a = 1.42

.39

 Good

86.6 % (13)

68.7 % (11)

  

Psychiatric disorder

 Yes

93.3 % 14

87.5 % 14

χ2a = .43

.60

 No

6.6 % (1)

12.5 % (2)

  

Major depressive episode

 Yes

60 % (9)

62.5 % (10)

χ2a = .02

1

 No

40 % (6)

37.5 % (6)

  

Major depressive episode recurrent

 Yes

53.3 % (8)

25 % (4)

χ2a = .2.62

.14

 No

46.6 % (7)

75 % (12)

  

Risk for suicide

 No

53.3 % (8)

62.5 % (10)

χ2 = 1.63

.65

 Mild

33.3 % (5)

25 % (4)

  

 Moderate

6.6 % (1)

12.5 % (2)

  

 High

6.6 % (1)

0 % (0)

  

The groups were also balanced in diagnosis of the other psychiatric disorders assessed: panic disorder without agoraphobia χ2 (1) = .16, p = 1, with agoraphobia χ2 (1) = .07, p = 1 and agoraphobia without history of panic disorder χ2 (1) = 3.54, p = 0.1 and in the presence of comorbidity between depression and anxiety χ2 (1) = .01, p = 1.

Comparison Between Groups

Table 2 shows the means, standard deviations and one-way ANOVA for MBCT and CG at the moments of measure: pre-test, post-test and follow-up.
Table 2

Means, standard deviations and one-way variance analysis for the effects of MBCT on the variables of FIQ, BDI and VAS pain

Variable/moment

MBCT

(n = 15)

CG

(n = 16)

ANOVA

M

SD

M

SD

F(1, 29)

p

FIQ

 Pre

77.09

13.45

64.74

14.06

6.23*

.02

 Post

61.77

13.65

66.20

17.22

.62

.43

 Follow-up

63.25

15.80

70.77

10.54

2.46

.12

BDI

 Pre

18.60

7.20

16.88

5.85

.53

.46

 Post

13.00

6.35

15.44

6.88

1.04

.31

 Follow-up

13.13

5.34

17.75

5.86

5.24*

.03

VAS (cervical)

 Pre

2.11

.25

2.00

.35

1.02

.32

 Post

2.04

.20

2.07

.21

.17

.68

 Follow-up

2.02

.27

2.06

.11

.24

.62

VAS (dorsal)

 Pre

2.02

.57

1.77

.59

1.37

.25

 Post

1.95

.28

2.01

.22

.39

.53

 Follow-up

1.98

.23

1.98

.15

.01

.91

VAS (lumbar)

 Pre

2.17

.19

2.05

.22

2.37

.13

 Post

2.06

.16

2.02

.29

.28

.60

 Follow-up

2.11

.15

2.09

.16

.11

.73

VAS (right arm)

 Pre

1.77

.76

1.81

.55

.02

.87

 Post

1.78

.55

1.94

.26

1.20

.28

 Follow-up

1.72

.59

1.95

.21

2.12

.15

VAS (left arm)

 Pre

1.51

.84

1.75

.55

.87

.35

 Post

1.60

.46

1.80

.29

2.06

.16

 Follow-up

1.58

.61

1.90

.25

3.57

.06

VAS (right leg)

 Pre

1.84

.66

1.65

.63

.67

.41

 Post

1.83

.42

1.87

.37

.07

.79

 Follow-up

1.76

.45

1.90

.20

1.31

.26

VAS (left leg)

 Pre

1.75

.56

1.80

.38

.09

.76

 Post

1.76

.41

1.76

.39

.00

.99

 Follow-up

1.62

.60

1.92

.29

3.15

.08

* p < .05

Significant differences were found between both groups in the FIQ variable before beginning treatment. Therefore, an ANCOVA was conducted with the pre-test value of the FIQ variable as covariate (Table 4). The one-way ANOVA results (Table 2) show significant differences in the depressive symptoms between MBCT and CG in the follow-up. This five-point reduction can be seen in the post-test although it is not significant. Regarding intensity of pain, no significant differences were found in any of the body areas assessed. The intra-group changes, the effect size and the percentage of change need to be studied.

Intra-group Comparison

The evolution of the intra-group data (Table 3), shows significant pre-test-post-test and pre-test-follow-up differences in the MBCT group and the FIQ and BDI variables. The value for lumbar pain intensity decreases significantly after treatment although this decrease does not continue in the follow-up. The effect size values in the variables and measures previously mentioned observed in the MBCT group are high (see Table 3). The percentages of change are considerable, being 19.87 and 30.10 % after treatment and 19.87 and 17.90 % after follow-up for FIQ and BDI variables respectively. Medium values were found in the reduction of VAS pain in the cervical area in the pre-test-post-test and pre-test-follow-up and a small effect size in the left leg in the pre-test-follow-up measure. In the CG, low values were found in effect size and percentage of change (8.53 and 5.15 %) in depressive symptoms in the pre-test-post-test measure.
Table 3

Differences in mean and effect size in the variables studied

 

MBCT (n = 15)

CG (n = 16)

IC 95 %

Variable/moment

t(14)

d

Lower limit

Upper limit

t(15)

d

Lower limit

Upper limit

FIQ

 Pre-post

6.79***

1.13

.33

1.87

−.54

−.09

−.78

.60

 Pre-follow-up

6.14***

.94

.17

1.67

−1.46

−.48

−1.18

.23

BDI

 Pre-post

5.50***

.82

.06

1.55

1.36

.22

−.48

.91

 Pre-follow-up

6.19***

.86

.09

1.59

−.71

−.14

−.84

.55

EVA (cervical)

 Pre-post

1.79

.31

−.42

1.02

−.89

−.24

−.93

.46

 Pre-follow-up

1.68

.34

−.38

1.06

−.70

−.23

−.92

.47

EVA (dorsal)

 Pre-post

.56

.15

−.57

.87

−1.42

−.54

−1.23

.18

 Pre-follow-up

.25

.09

−.62

.81

−1.24

−.48

−1.18

.23

EVA (lumbar)

 Pre-post

2.19*

.62

−.12

1.34

.44

.11

−.58

.81

 Pre-follow-up

1.56

.35

−.38

1.06

−.69

−.20

−.92

.47

EVA (right arm)

 Pre-post

−.03

−.01

−.73

.70

−1.28

−.30

−.99

.40

 Pre-follow-up

.33

.07

−.64

.78

−.97

−.33

−1.03

.37

EVA (left arm)

 Pre-post

−.50

−.13

−.85

.59

−.43

−.11

−.80

.58

 Pre-follow-up

−.37

−.09

−.81

.62

−1.07

−.35

−1.04

.36

EVA (right leg)

 Pre-post

.12

.02

−.70

−.73

−1.29

−.42

−1.12

.29

 Pre-follow-up

0.45

.14

−.58

.85

−1.49

−.53

−1.23

.18

EVA (left leg)

 Pre-post

−.09

−.02

−.74

.70

.43

.10

−.59

.79

 Pre-follow-up

.83

.22

−.50

.94

−.94

−.35

−1.04

.35

d = measure of Cohen’s size effect. *** p < .001, * p < .05

Effects of Treatment

The ANCOVA results for the FIQ variable (Table 4) indicate that, regardless of the pre-test value, significant differences exist in favour of the MBCT group. These differences are higher in the post-test, F(1, 28) = 5.47, p < .001, ŋ2 = .35) than 3 months after treatment, F(1, 28) = 8.82, p < .05, ŋ2 = .24).
Table 4

ANCOVA with covariance analysis (Pre) for impact of fibromyalgia

Source

Post

3-month-follow-up

df

F

p

ŋ2

df

F

p

ŋ2

Covariance (Pre)

1

44.37

.00

.61

1

10.03

.004

.26

Group

1

15.47

.001

.35

1

8.82

.006

.24

Error

28

(97.55)

  

28

(136.51)

  

The values in parenthesis represent the mean square errors

The data found in the 3 × 2 repeated measures ANOVA show that an intragroup time effect and a time × group interaction exist in the depressive symptoms variable (Table 5). These results indicate that the treatment reduces depressive symptoms and that this decrease is maintained over time.
Table 5

3x2 repeated measures ANOVA for the effects on the depressive symptom variable

Source

df

SS

MS

F

ŋ2

Group

1

73.29

73.29

.74

.02

Time (intragroup)

2

197.65

98.82

10.16***

.26

Time X group

2

160.75

80.37

8.26**

.22

Error (time)

58

564.06

9.72

  

Total

29

2865.95

98.82

  

*** p < .001, ** p < .01

Discussion

MBCT is considered to be effective in the treatment of depressive symptoms in women with fibromyalgia, decreasing the impact of fibromyalgia syndrome. Significant influences were found in the MBCT group on the improvement of these measures and the effect size of the intervention was found to be high. No significant differences between groups were found for the pain intensity variable in the different body zones assessed. Significant intragroup differences were found between pre-test and post-treatment results for the lumbar area.

The results indicate that the MBCT group significantly improved the impact of fibromyalgia in comparison with the CG. Taking into account the percentage of change in the MBCT group in both the pre-post and the follow-up comparison, we can say that the changes produced by the treatment are effective in the dysfunction of the symptoms caused by fibromyalgia, exceeding the clinically significant minimum percentage of change (14 %) proposed for the results of the FIQ (Bennett et al. 2009). The Cohen’s d index supports the conclusion that the effect size of the intervention is substantial.

These data are in line with previous research demonstrating the effectiveness of MBSR in the improvement of the physical condition of fibromyalgia patients who completed the program (Kaplan et al. 1993) and in the long-term maintenance of benefits to physical and emotional wellbeing after the intervention (Grossman et al. 2007). They also demonstrate the effectiveness of MBSR in the perceived improvement in health (Franco et al. 2010; Quintana and Rincón 2011), in the significant increase at a two-month follow-up in the disposition to experience life as more manageable (Weissbecker et al. 2002) and in a lower level of physical and psychological disability and greater daily activity (McCracken and Eccleston 2005).

The findings indicate that the treatment significantly reduced depressive symptoms in the MBCT group. This reduction was maintained in the 3-month follow-up. A large effect size was found for the treatment in the two measures (post-test and follow-up). The BDI score for the MBCT group, according to the chosen cut off points, went from moderate in pre-test to mild in post-test and follow-up. These results concur with the findings of other studies which demonstrate that MBSR reduces depressive symptoms after intervention and in the long term (Bohlmeijer et al. 2010; Grossman et al. 2007; Kabat-Zinn et al. 1985; Quintana and Rincón 2011; Sephton et al. 2007).

The significant decrease in the impact of fibromyalgia and depressive symptoms after MBCT leads us to believe, according to the model of Segal et al. (2002), that the practice of mindfulness helps patients to interrupt patterns of depressogenic reactivity as an emotional response to their pain and physical dysfunction. Patients have probably learnt to relate to their automatic thoughts about pain and their different pain sensations with an attitude of acceptance and openness and in a non-reactive and non-judgemental way that is more beneficial for their health, as several studies suggest. Although unfortunately in this study we have not measured the components of mindfulness, this improvement could be explained by the following mechanisms of action underlying the practice of mindfulness: acceptance, exposure, nonattachment, insight, enhanced mind–body functioning, integrated functioning, cognitive change and self-management (Baer 2003; Brown et al. 2007). In addition it has been demonstrated that the cultivation of self-compassion is a mediating variable in the positive effects of MBCT on depressive symptoms (Kuyken et al. 2010). Sephton et al. (2007) suggest that experience in mindfulness can help patients disengage from the emotional response to pain and brings an end to the ruminations which probably trigger the depressive symptoms. It has also been shown that the mindfulness attitudes of acceptance and self-regulation of attention are associated with a reduction of negative repetitive thought, such as worry, (Evans and Segerstrom 2011) and that the mindfulness components of acting consciously and awareness of the present moment correlate significantly with aspects of chronic pain (McCracken and Thompson 2009).

Regarding the pain intensity variable, our analyses show no significant differences between groups in the different body areas assessed. It should be noted that after treatment significant intragroup differences exist in lumbar pain intensity. In previous research fibromyalgia patients who followed MBSR therapy reported a decrease in the intensity of pain (Franco et al. 2010; Kaplan et al. 1993; Grossman et al. 2007; McCracken and Thompson 2009; Quintana and Rincón 2011). Our data for this variable coincide with the results found in other studies (Cusens et al. 2010; Schmidt et al. 2011) in which fibromyalgia patients who participated in Breathworks Mindfulness-Based Pain Management Programme and MBSR, respectively, did not improve significantly the intensity of their pain after intervention. The systematic review conducted by Chiesa and Serretti (2011) on mindfulness-based therapy in patients with chronic pain suggests that it is important to continue research into the specific effects this therapy might have on the reduction of symptoms of pain and depression. The authors point out that there exists no empirical evidence that this type of therapy is more effective than others, especially in the reduction of pain.

We suggest that when assessing pain it is not only important to quantify the intensity of pain but also the degree to which patients perceive the pain stimulus as adverse or discomforting and whether they feel they can make use of valid response strategies. It has been shown that mindfulness training using MBCT correlates significantly with the reduction in avoidance strategies and rumination (Kumar et al. 2008) and that continued mindfulness practice lessens the relationship between intensity of pain and pain catastrophizing (Schütze et al. 2010). (Cusens et al. 2010) found a significant increasing in pain acceptance variable and significant decrease in pain catastrophizing and pain self-efficacy variables after Breathworks Mindfulness-Based Pain Management Programme. Evidence has shown that the practice of mindfulness reduces avoidance of pain-related threat at early stages of processing and therefore facilitates disengagement from pain-related threat in later stages (Vago and Nakamura 2011).

We believe it is important to study these variables together with the specific components of mindfulness, since this might be the key to why the patients in our study report improved mood state, and achieved lower level of dysfunction caused by the symptoms of fibromyalgia and an insignificant change in the intensity of pain.

There are a number of limitations to this study which must be taken into consideration. Firstly, measures of the changes in the mindfulness variables were not obtained since there were no scales validated in Spanish when the study was begun. For future research it is important to study which specific components of mindfulness may be related to the improvement of health in patients with fibromyalgia. It is also important to analyse the possible differences between the components of MBSR and MBCT interventions. Secondly, our study did not collect data on the daily practice of mindfulness during follow-up. We believe that in the future this information would be useful and could even be obtained using software which objectively records the conduct of patients during the practice of mindfulness. It is fundamental to monitor continually the pain intensity variable to verify its fluctuation over time. We consider that if one or more follow-up sessions had been conducted during this stage, the intervention would have been more effective since it would probably have increased the amount of daily practice. Thirdly, it is necessary to make the follow-up period longer so as to verify whether the improvement to symptoms is maintained and if more mindfulness practice could significantly reduce the intensity of pain. Fourthly, the small sample size and the fact that the participants were members of a fibromyalgia association limit, to some degree, the external validity of the results. In future studies a larger sample size would be appropriate. In this way, it could be possible to study the influence of moderator variables such as psychiatric disorders or the time of daily practice of the different mindfulness meditations. It would also then be possible to block variables such as use of medication, number of previous psychological treatments or membership of fibromyalgia associations.

In general, the results of our study show that in women with fibromyalgia, MBCT is effective in reducing the impact of the disease and in decreasing depressive symptomatology after treatment and in the three-month follow-up. These findings have importance for clinical practice since it has been observed that after MBCT, there is a significant reduction of depressive symptoms and the impact of fibromyalgia despite there being no change in pain intensity. It would be interesting to continue research along these lines since this type of group intervention based on mindfulness and cognitive therapy could achieve long-term changes which maintain the increase in emotional and physical wellbeing of persons with fibromyalgia.

Acknowledgments

We would like to give our thanks to the Fibromyalgia Association of Almansa for their collaboration and a special warm thank you to all those who participated in our study.

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Marta Parra-Delgado
    • 1
    • 2
    • 3
  • José Miguel Latorre-Postigo
    • 1
    • 2
  1. 1.Department of PsychologyUniversity of Castilla-La ManchaAlbaceteSpain
  2. 2.Applied Cognitive Psychology UnitNeurological Disabilities Research InstituteAlbaceteSpain
  3. 3.Departamento de PsicologíaFacultad de EducaciónAlbaceteSpain

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