Abstract
BACKGROUND AND OBJECTIVE
Affect and how it is regulated plays a role in pain perception, maintenance of pain, and its resolution. This randomized, controlled trial evaluated an innovative affective self-awareness (ASA) intervention, which was designed to reduce pain and improve functioning in individuals with fibromyalgia.
PARTICIPANTS AND METHODS
Forty-five women with fibromyalgia were randomized to a manualized ASA intervention (n = 24) or wait-list control (n = 21). The intervention began with a one-time physician consultation, followed by 3 weekly, 2-h group sessions based upon a mind-body model of pain. Sessions focused on structured written emotional disclosure and emotional awareness exercises. Outcomes in both conditions were measured by a blinded assessor at baseline, post-intervention, and 6-month follow-up.
MEASURES
The primary outcome was pain severity (Brief Pain Inventory); secondary outcomes included tender-point threshold and physical function (SF-36 Physical Component Summary). Intent-to-treat analyses compared groups on outcomes using analysis of covariance and on the proportion of patients achieving ≥30% and ≥50% pain reduction at 6 months.
RESULTS
Adjusting for baseline scores, the intervention group had significantly lower pain severity (p < 0.001), higher self-reported physical function (p < 0.001), and higher tender-point threshold (p = 0.02) at 6 months compared to the control group. From baseline to 6 months, 45.8% of the ASA intervention group had ≥30% reduction in pain severity, compared to none of the controls (p < 0.001).
CONCLUSIONS
The affective self-awareness intervention improved pain, tenderness, and self-reported physical function for at least 6 months in women with fibromyalgia compared to wait-list control. This study suggests the value of interventions targeting emotional processes in fibromyalgia, although further studies should evaluate the efficacy of this intervention relative to active controls.
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References
Wolfe F, Smythe HA, Yunus MB, et al. The American College of rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160–72.
Aaron LA, Buchwald D. Chronic diffuse musculoskeletal pain, fibromyalgia and co-morbid unexplained clinical conditions. Best Pract Res Clin Rheumatol. 2003;17:563–74.
Arnold LM, Bradley LA, Clauw DJ, Glass JM, Goldenberg DL. Evaluating and diagnosing fibromyalgia and comorbid psychiatric disorders. J Clin Psychiatry. 2008;69:e28.
Wolfe F, Ross K, Anderson J, Russell IJ. Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol. 1995;22:151–6.
Williams DA, Clauw DJ. Understanding fibromyalgia: lessons from the broader pain research community. J Pain. 2009;10:777–91.
Geisser ME, Glass JM, Rajcevska LD, et al. A psychophysical study of auditory and pressure sensitivity in patients with fibromyalgia and healthy controls. J Pain. 2008;9:417–22.
Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. 2007;36:339–56.
Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med. 2008;70:430–4.
Baumgartner E, Finckh A, Cedraschi C, Vischer TL. A 6 year prospective study of a cohort of patients with fibromyalgia. Ann Rheum Dis. 2002;61:644–5.
Wolfe F, Anderson J, Harkness D, et al. Health status and disease severity in fibromyalgia: results of a six-center longitudinal study. Arthritis Rheum. 1997;40:1571–9.
Jackson JL, Kroenke K. Managing somatization: medically unexplained should not mean medically ignored. J Gen Intern Med. 2006;21:797–9.
Crofford LJ, Mease PJ, Simpson SL, et al. Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin. Pain. 2008;136:419–31.
Russell IJ, Mease PJ, Smith TR, et al. Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with or without major depressive disorder: results from a 6-month, randomized, double-blind, placebo-controlled, fixed-dose trial. Pain. 2008;136:432–44.
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292:2388–95.
Williams DA, Cary MA, Groner KH, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatology. 2002;29:1280–6.
White KP, Nielson WR. Cognitive behavioral treatment of fibromyalgia syndrome: a followup assessment. J Rheumatol. 1995;22:717–21.
Hassett AL, Bevirtz RN. Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheum Dis Clin N Am. 2009;35:393–407.
Van Houdenhove B, Luyten P. Stress, depression and fibromyalgia. Acta Neurol Belg. 2006;106:149–56.
Van Houdenhove B, Egle U, Luyten P. The role of life stress in fibromyalgia. Curr Rheumatol Rep. 2005;7:365–70.
Walker EA, Keegan D, Gardner G, Sullivan M, Bernstein D, Katon WJ. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosom Med. 1997;59:572–7.
Arnold LM, Hudson JI, Keck PE, Auchenbach MB, Javaras KN, Hess EV. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry. 2006;67:219–25.
Sherman JJ, Turk DC, Okifuji A. Prevalence and impact of posttraumatic stress disorder-like symptoms on patients with fibromyalgia syndrome. Clin J Pain. 2000;16:127–34.
Raphael KG, Janal MN, Nayak S. Comorbidity of fibromyalgia and posttraumatic stress disorder symptoms in a community sample of women. Pain Med. 2004;5:33–41.
Kivimäki M, Leino-Arjas P, Virtanen M, et al. Work stress and incidence of newly diagnosed fibromyalgia: prospective cohort study. J Psychosom Res. 2004;57:417–22.
Horowitz MJ. Stress-response syndromes: a review of posttraumatic and adjustment disorders. Hosp Community Psychiatry. 1986;37:241–9.
Dailey PA, Bishop GD, Russell IJ, Fletcher EM. Psychological stress and the fibrositis/fibromyalgia syndrome. J Rheumatol. 1990;17:1380–5.
Brosschot JF, Aarsse HR. Restricted emotional processing and somatic attribution in fibromyalgia. Int J Psychiatry Med. 2001;31:127–46.
van Middendorp H, Lumley MA, Jacobs JWG, van Doornen LJP, Bijlsma JWJ, Geenen R. Emotions and emotional approach and avoidance strategies in fibromyalgia. J Psychosom Res. 2008;64:159–67.
Sayar K, Gulec H, Topbas M. Alexithymia and anger in patients with fibromyalgia. Clin Rheumatol. 2004;23:441–8.
Finan PH, Zautra AJ, Davis MC. Daily affect relations in fibromyalgia patients reveal positive affective disturbance. Psychosom Med. 2009;71:474–82.
Sarno JE. The Mindbody Prescription: Healing the Body, Healing the Pain. New York: Warner Books; 1998.
Selfridge N, Peterson F. Freedom from Fibromyalgia. New York: Three Rivers Press; 2001.
Torres X, Collado A, Arias A, et al. Pain locus of control predicts return to work among Spanish fibromyalgia patients after completion of a multidisciplinary pain program. Gen Hosp Psychiatry. 2009;31:137–45.
Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317–32.
McCracken LM, Vowles KE, Eccleston C. Acceptance of chronic pain: component analysis and a revised assessment method. Pain. 2004;107:159–66.
Gillis ME, Lumley MA, Mosley-Williams A, Leisen JC, Roehrs T. The health effects of at-home written emotional disclosure in fibromyalgia: a randomized trial. Ann Behav Med. 2006;32:135–46.
Broderick JE, Junghaenel DU, Schwartz JE. Written emotional expression produces health benefits in fibromyalgia patients. Psychosom Med. 2005;67:326–34.
Smyth J, Helm R. Focused expressive writing as self-help for stress and trauma JCLP/In Session: Psychotherapy in Practice. 2003;59:227–35.
Pennebaker JW, Susman JR. Disclosure of traumas and psychosomatic processes. Soc Sci Med. 1988;26:327–32.
Grossman P, Tiefenthaler-Gilmer U, Raysz A, Kesper U. Mindfulness training as an intervention for fibromyalgia: evidence of post-intervention and 3-year follow-up benefits in well-being. Psychother Psychosom. 2007;76:226–33.
Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33.
Schubiner H, Betzold M. Unlearn Your Pain. Pleasant Ridge, MI: Mind Body Publishing; 2010.
Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994;23:129–38.
Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of the Brief Pain Inventory for chronic nonmalignant pain. J Pain. 2004;5:133–7.
Ware JE, Kosinski M, Dewey J. How to Score Version Two of the SF-36r Health Survey. Lincoln, RI: QualityMetric, Inc; 2000.
Smets EM, Garssen B, Bonke B, DeHaes JC. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39:315–25.
Stewart AL, Ware JEJ, eds. Measuring Functioning and Well-being: The Medical Outcomes Study Approach. Durham NC: Duke University Press; 1992.
Skevington SM. A standardized scale to measure beliefs about controlling pain. (BPCQ): a preliminary study. Psychol Health. 1990;4:221–32.
Petzke F, Clauw DJ, Ambrose K, Khine A, Gracely RH. Increased pain sensitivity in fibromyalgia: effects of stimulus type and mode of presentation. Pain. 2003;105:403–13.
Fischer AA. Pressure threshold meter: its use for quantification of tender spots. Arch Phys Med Rehabil. 1986;67:836–8.
Arnold LM, Pritchett YL, D'Souza DN, Kajdasz DK, Iyengar S, Wernicke JF. Duloxetine for the treatment of fibromyalgia in women: pooled results from two randomized, placebo-controlled clinical trials. J Womens Health (Larchmt). 2007;16:1145–56.
Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56:1336–44.
Arnold LM, Lu Y, Crofford LJ, et al. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis Rheum. 2004;50:2974–84.
Ang D, Kesavalu R, Lydon JR, Lane KA, Bigatti S. Exercise-based motivational interviewing for female patients with fibromyalgia: a case series. Clin Rheumatol. 2007;26:1843–9.
Clauw DJ, Mease P, Palmer RH, Gendreau RM, Wang Y. Milnacipran for the treatment of fibromyalgia in adults: a 15-week, multicenter, randomized, double-blind, placebo-controlled, multiple-dose clinical trial. Clin Ther. 2008;30:1988–2004.
Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: a randomized controlled trial. Clin J Pain. 2005;21:166–74.
Thieme K, Gromnica-Ihle E, Flor H. Operant behavioral treatment of fibromyalgia: a controlled study. Arthritis Rheum. 2003;49:314–20.
Mannerkorpi K, Nyberg B, Ahlmén M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol. 2000;27:2473–81.
Evcik D, Kizilay B, Gökçen E. The effects of balneotherapy on fibromyalgia patients. Rheumatol Int. 2002;22:56–9.
Burns JW, Quartana P, Gilliam W, et al. Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model. Health Psychol. 2008;27:645–52.
Kop WJ, Lyden A, Berlin AA, et al. Ambulatory monitoring of physical activity and symptoms in fibromyalgia and chronic fatigue syndrome. Arthritis Rheum. 2005;52:296–303.
Acknowledgments
Our research was supported in part by the Scott F. Nadler, DO, Research Grant (Physiatric Association of Spine, Sports, and Occupational Rehabilitation); and by grant numbers U020912 (Michigan Institute of Clinical and Health Research); T32-HD007422, K12HD001097 (NICHD/NIH); AR049059, (NIAMS/NIH); and DAMD 17-00-2-0018 (Department of Defense).
These data were presented at the American Academy of Physical Medicine and Rehabilitation; November 22, 2008; San Diego, CA, and the North American Research Council for Complementary and Integrative Medicine, May 14, 2009, Minneapolis, MN.
Conflict of interest statement
There is one potential conflict of interest to report. Dr. Schubiner developed the program used in this study. He conducts this program at Providence Hospital and on the Internet. It is unlikely that this was a significant factor in this study since Dr. Hsu, who performed all of the baseline and outcome assessments and all data analyses, remained a blinded assessor throughout the study.
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Supported in part by the Scott F. Nadler, DO, Research Grant (Physiatric Association of Spine, Sports, and Occupational Rehabilitation) and by grant numbers U020912 (Michigan Institute of Clinical and Health Research); T32-HD007422, K12HD001097 (NICHD/NIH); AR049059 (NIAMS/NIH); and DAMD 17-00-2-0018 (Department of Defense).
Clinicaltrials.gov identifier NCT00437411
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Hsu, M.C., Schubiner, H., Lumley, M.A. et al. Sustained Pain Reduction Through Affective Self-awareness in Fibromyalgia: A Randomized Controlled Trial. J GEN INTERN MED 25, 1064–1070 (2010). https://doi.org/10.1007/s11606-010-1418-6
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DOI: https://doi.org/10.1007/s11606-010-1418-6