Journal of Behavioral Medicine

, Volume 37, Issue 4, pp 683–697 | Cite as

Cognitive-behavioral therapy for insomnia and sleep hygiene in fibromyalgia: a randomized controlled trial

  • M. Pilar Martínez
  • Elena Miró
  • Ana I. Sánchez
  • Carolina Díaz-Piedra
  • Rafael Cáliz
  • Johan W. S. Vlaeyen
  • Gualberto Buela-Casal


Sleep disturbances play an important role in the exacerbation of pain and other troubling symptoms reported by patients with fibromyalgia (FM). The objective of this trial was to analyze the efficacy of a cognitive-behavioral therapy for insomnia (CBT-I) versus a sleep hygiene (SH) education program at improving sleep and other clinical manifestations in FM. Sixty-four FM women with insomnia were randomly assigned to the CBT-I or the SH groups, and 59 completed the treatments (30 in the CBT-I group and 29 in the SH group). Participants completed several self-report questionnaires at pre-, post-treatment and follow-ups. The CBT-I group reported significant improvements at post-treatment in several sleep variables, fatigue, daily functioning, pain catastrophizing, anxiety and depression. The SH group only improved significantly in subjective sleep quality. Patients in the CBT-I group showed significantly greater changes than those in the SH group in most outcome measures. The findings underscore the usefulness of CBT-I in the multidisciplinary management of FM.


Fibromyalgia Insomnia Cognitive-behavioral therapy Sleep hygiene Randomized controlled trial 



This research was financially supported by the Spanish Ministry of Science and Innovation (research project SEJ2006-07513). CDP is supported by a FPU grant from the Spanish Ministry of Education (AP 2007-02965). Research by GBC is funded by Spanish Ministry of Science and Innovation grant (INNPACTO IPT300000-2010-10) and by Spanish Ministry of Education grant (EDU2010-21215).


  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th. ed. rev.). Washington, DC: American Psychiatric Association.Google Scholar
  2. Anderson, K. O., Dowds, B. N., Pelletz, R. E., Edwards, W. T., & Peeters-Asdourian, C. (1995). Development and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain. Pain, 63, 77–83. doi: 10.1016/0304-3959(95)00021-J PubMedCrossRefGoogle Scholar
  3. Andersson, G., Johansson, C., Nordlander, A., & Asmundson, G. J. G. (2012). Chronic pain in older adults: A controlled pilot trial of a brief cognitive-behavioural group treatment. Behavioural and Cognitive Psychotherapy, 40, 239–244. doi: 10.1017/S1352465811000646 PubMedCrossRefGoogle Scholar
  4. Backhaus, J., Junghanns, K., Broocks, A., Riemann, D., & Hohagen, F. (2002). Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. Journal of Psychosomatic Research, 53, 737–740. doi: 10.1016/S0022-3999(02)00330-6 PubMedCrossRefGoogle Scholar
  5. Belt, N. K., Kronholm, E., & Kauppi, M. J. (2009). Sleep problems in fibromyalgia and rheumatoid arthritis compared with the general population. Clinical and Experimental Rheumatology, 27, 35–41.PubMedGoogle Scholar
  6. Bigatti, S. M., Hernandez, A. M., Cronan, T. A., & Rand, K. L. (2008). Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression. Arthritis Care and Research, 59, 961–967. doi: 10.1002/art.23828 PubMedCentralPubMedCrossRefGoogle Scholar
  7. Burckhardt, C. S., Clark, S. R., & Bennett, R. M. (1991). The Fibromyalgia Impact Questionnaire: Development and validation. Journal of Rheumatology, 18, 728–733.PubMedGoogle Scholar
  8. Buysse, D. J., Hall, M. L., Strollo, P. J., Kamarck, T. W., Owens, J., Lee, L., et al. (2008). Relationships between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and clinical/polysomnographic measures in a community sample. Journal of Clinical Sleep Medicine, 4, 563–571.PubMedCentralPubMedGoogle Scholar
  9. Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213.PubMedCrossRefGoogle Scholar
  10. Buysse, D. J., Reynolds, C. F., Monk, T. H., Hoch, C. C., Yeager, A. L., & Kupfer, D. J. (1991). Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality Index (PSQI). Sleep, 14, 331–338.PubMedGoogle Scholar
  11. Cohen, J. (1988). Statistical power analysis for the behavior sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.Google Scholar
  12. Cole, J. C., Dubois, D., & Kosinski, M. (2007). Use of patient-reported sleep measures in clinical trials of pain treatment: A literature review and synthesis of current sleep measures and a conceptual model of sleep disturbance in pain. Clinical Therapeutics, 29, 2580–2588. doi: 10.1016/j.clinthera.2007.12.005 PubMedCrossRefGoogle Scholar
  13. Cook, D. B., Lange, G., Ciccone, D. S., Liu, W. C., Steffener, J., & Natelson, B. H. (2004). Functional imaging of pain in patients with primary fibromyalgia. Journal of Rheumatology, 31, 364–378.PubMedGoogle Scholar
  14. Currie, S. R., Wilson, K. G., Pontefract, A. J., & deLaplante, L. (2000). Cognitive-behavioral treatment of insomnia secondary to chronic pain. Journal of Consulting and Clinical Psychology, 68, 407–416. doi: 10.1037/0022-006X.68.3.407 PubMedCrossRefGoogle Scholar
  15. Davies, K. A., Macfarlane, G. J., Nicholl, B. I., Dickens, C., Morriss, R., Ray, D., et al. (2008). Restorative sleep predicts the resolution of chronic widespread pain: Results from the EPIFUND study. Rheumatology, 47, 1809–1813. doi: 10.1093/rheumatology/ken389 PubMedCentralPubMedCrossRefGoogle Scholar
  16. Derogatis, L. R. (2002). SCL-90-R. Cuestionario de 90 síntomas. [SCL-90-R. Symptom checklist 90 revised]. Madrid: TEA Ediciones (Orig. 1994).Google Scholar
  17. Edinger, J. D., Wohlgemuth, W. K., Krystal, A. D., & Rice, J. R. (2005). Behavioral insomnia therapy for fibromyalgia patients. A randomized clinical trial. Archives of Internal Medicine, 165, 2527–2535. doi: 10.1001/archinte.165.21.2527 PubMedCrossRefGoogle Scholar
  18. Fillion, L., Gélinas, C., Simard, S., Savard, J., & Gagnon, P. (2003). Validation evidence for the French Canadian adaptation of the Multidimensional Fatigue Inventory as a measure of cancer-related fatigue. Cancer Nursing, 26, 143–154.PubMedCrossRefGoogle Scholar
  19. García-Campayo, J., Rodero, R., Alda, M., Sobradiel, N., Montero, J., & Moreno, S. (2008). Validación de la versión española de la Escala de la Catastrofización ante el Dolor (Pain Catastrophizing Scale) en la fibromialgia [Validation of the Spanish version of the Pain Catastrophizing Scale in fibromyalgia]. Medicina Clínica, 131, 487–492. doi: 10.1157/13127277 PubMedCrossRefGoogle Scholar
  20. Gatzounis, R., Schrooten, M. G. S., Crombez, G., & Vlaeyen, J. W. S. (2012). Operant learning theory in pain and chronic pain rehabilitation. Current Pain and Headache Reports, 16, 117–126. doi: 10.1007/s11916-012-0247-1 PubMedCrossRefGoogle Scholar
  21. Glombiewski, J. A., Sawyer, A. T., Gutermann, J., Koenig, K., Rief, W., & Hofmann, S. G. (2010). Psychological treatments for fibromyalgia: A meta-analysis. Pain, 151, 280–295. doi: 10.1016/j.pain.2010.06.011 PubMedCrossRefGoogle Scholar
  22. Gracely, R. H., Petzke, F., Wolf, J. M., & Clauw, D. J. (2002). Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis of Rheumathology, 46, 1333–1343. doi: 10.1002/art.10225 CrossRefGoogle Scholar
  23. Hamilton, N. A., Affleck, G., Tennen, H., Karlson, C., Luxton, D., Preacher, K. J., et al. (2008). Fibromyalgia: The role of sleep in affect and in negative event reactivity and recovery. Health Psychology, 27, 490–497. doi: 10.1037/0278-6133.27.4.490 PubMedCrossRefGoogle Scholar
  24. Hamilton, N. A., Presman, M., Lillis, T., Atchley, R., Karlson, C., & Stevens, N. (2012). Evaluating evidence for the role of sleep in fibromyalgia: A test of the sleep and pain diathesis model. Cognitive Therapy and Research, 36, 806–814. doi: 10.1007/s10608-011-9421-8 PubMedCentralPubMedCrossRefGoogle Scholar
  25. Hassett, A. L., & Gevirtz, R. N. (2009). Nonpharmacologic treatment for fibromyalgia: Patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheumatic Disease Clinics of North America, 35, 393–407. doi: 10.1016/j.rdc.2009.05.003 PubMedCentralPubMedCrossRefGoogle Scholar
  26. Häuser, W., Thieme, K., & Turk, D. C. (2010). Guidelines on the management of fibromyalgia syndrome. A systematic review. European Journal of Pain, 14, 5–10. doi: 10.1016/j.ejpain.2009.01.006 PubMedCrossRefGoogle Scholar
  27. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19. doi: 10.1037//0022-006X.59.1.12 PubMedCrossRefGoogle Scholar
  28. Jiménez-Genchi, A., Monteverde-Maldonado, E., Nenclares-Portocarrero, A., Esquivel-Adame, G., & de la Vega-Pacheco, A. (2008). Confiabilidad y análisis factorial de la versión en español del índice de calidad de sueño de Pittsburgh en pacientes psiquiátricos [Reliability and factorial analysis of the Spanish version of the Pittsburg Sleep Quality Index among psychiatric patients]. Gaceta Médica de México, 144, 491–496.PubMedGoogle Scholar
  29. Jungquist, C. R., O’Brien, C., Matteson-Rusby, S., Smith, M. T., Pigeon, W. R., Xia, Y., et al. (2010). The efficacy of cognitive behavioral therapy for insomnia in patients with chronic pain. Sleep Medicine, 11, 302–309. doi: 10.1016/j.sleep.2009.05.018 PubMedCentralPubMedCrossRefGoogle Scholar
  30. Keefe, F. J., Rumble, M. E., Scipio, C. D., Giordano, L. A., & Perri, L. M. (2004). Psychological aspects of persistent pain: Current state of the science. The Journal of Pain, 5, 195–211. doi: 10.1016/j.jpain.2004.02.576 PubMedCrossRefGoogle Scholar
  31. Lachaine, J., Beauchemin, C., & Landry, P. A. (2010). Clinical and economic characteristics of patients with fibromyalgia syndrome. Clinical Journal of Pain, 26, 284–290. doi: 10.1097/AJP.0b013e3181cf599f PubMedCrossRefGoogle Scholar
  32. Lambert, M. J., & Ogles, B. M. (2009). Using clinical significance in psychotherapy outcome research: The need for a common procedure and validity data. Psychotherapy Research, 19, 493–501. doi: 10.1080/10503300902849483 PubMedCrossRefGoogle Scholar
  33. Lawrence, R. C., Felson, D. T., Helmick, C. G., Arnold, L. M., Choi, H., Deyo, R. A., et al. (2008). Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis and Rheumatism, 58, 26–35. doi: 10.1002/art.23176 PubMedCentralPubMedCrossRefGoogle Scholar
  34. Lázaro, C., Caseras, X., Whizar-Lugo, V. M., Wenk, R., Baldioceda, F., Bernal, R., et al. (2001). Psychometric properties of a Spanish version of the McGill Pain Questionnaire in several Spanish-speaking countries. The Clinical Journal of Pain, 17, 365–374.PubMedCrossRefGoogle Scholar
  35. Lee, Y. C., Nassikas, N. J., & Clauw, D. J. (2011). The role of the central nervous system in the generation and maintenance of chronic pain in rheumatoid arthritis, osteoarthritis and fibromyalgia. Arthritis Research and Therapy, 13, 211. doi: 10.1186/ar3306 PubMedCentralPubMedCrossRefGoogle Scholar
  36. Leeuw, M., Goossens, M. E., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. S. (2007). The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30, 77–94. doi: 10.1007/s10865-006-9085-0 PubMedCrossRefGoogle Scholar
  37. Martín-Aragón, M., Pastor, M. A., Rodríguez-Marín, J., March, M. J., Lledó, A., López-Roig, S., et al. (1999). Percepción de autoeficacia en dolor crónico. Adaptación y validación de la Chronic Pain Self-efficacy Scale [Perceived self-efficacy in chronic pain. Adaptation and validation of the Chronic Pain Self-efficacy Scale]. Revista de Psicología de la Salud, 11, 53–75.Google Scholar
  38. Mas, A. J., Carmona, L., Valverde, M., Ribas, B., & the EPISER Study Group. (2008). Prevalence and impact of fibromyalgia on function and quality of life in individuals from the general population: Results from a nationwide study in Spain. Clinical and Experimental Rheumatology, 26, 519–526.PubMedGoogle Scholar
  39. Melzack, R. (1987). The short form McGill Pain Questionnaire. Pain, 30, 191–197.PubMedCrossRefGoogle Scholar
  40. Meulders, A., Vansteenwegen, D., & Vlaeyen, J. W. S. (2011). The acquisition of fear of movement-related pain and associative learning: A novel pain-relevant human fear conditioning paradigm. Pain, 152, 2460–2469. doi: 10.1016/j.pain.2011.05.015 PubMedCrossRefGoogle Scholar
  41. Miró, E., Lupiáñez, J., Hita, E., Martínez, M. P., Sánchez, A. I., & Buela-Casal, G. (2011a). Attentional deficits in fibromyalgia and its relationships with pain, emotional distress and sleep dysfunction complaints. Psychology and Health, 26, 765–780. doi: 10.1080/08870446.2010.493611 PubMedCrossRefGoogle Scholar
  42. Miró, E., Lupiáñez, J., Martínez, M. P., Sánchez, A. I., Díaz-Piedra, C., Guzmán, M. A., et al. (2011b). Cognitive-behavioral therapy for insomnia improves attentional function in fibromyalgia syndrome: A pilot, randomized controlled trial. Journal of Health Psychology, 16, 770–782. doi: 10.1177/1359105310390544 PubMedCrossRefGoogle Scholar
  43. Miró, E., Martínez, M. P., Sánchez, A. I., Prados, G., & Medina, A. (2011c). When is pain related to emotional distress and daily functioning in fibromyalgia syndrome? The mediating roles of self-efficacy and sleep quality. British Journal of Health Psychology, 16, 799–814. doi: 10.1111/j.2044-8287.2011.02016.x PubMedCrossRefGoogle Scholar
  44. Moher, D., Hopewell, S., Schulz, K. F., Montori, V., Gøtzsche, P. C., Devereaux, P. J., et al. (2010). CONSORT 2010. Explanation and elaboration: Updated guidelines for reporting parallel group randomised trials. British Medical Journal, 340, c869. doi: 10.1136/bmj.c869 PubMedCentralPubMedCrossRefGoogle Scholar
  45. Moldofsky, H. (2009). The significance of dysfunctions of the sleeping/waking brain to the pathogenesis and treatment of fibromyalgia syndrome. Rheumatic Diseases Clinics of North America, 35, 275–283. doi: 10.1016/j.rdc.2009.05.008 PubMedCrossRefGoogle Scholar
  46. Moldofsky, H. (2010). Rheumatic manifestations of sleep disorders. Current Opinion in Rheumatology, 22, 59–63. doi: 10.1097/BOR.0b013e328333b9cc PubMedCrossRefGoogle Scholar
  47. Morgenthaler, T., Kramer, M., Alessi, C., Friedman, L., Boehlecke, B., Brown, T., et al. (2006). Practice parameters for the psychological and behavioral treatment of insomnia: An update. An American Academy of Sleep Medicine Report. Sleep, 29, 1415–1419.PubMedGoogle Scholar
  48. Mork, P. J., & Nilsen, T. I. (2012). Sleep problems and risk of fibromyalgia: Longitudinal data on an adult female population in Norway. Arthritis and Rheumatism, 64, 281–284. doi: 10.1002/art.33346 PubMedCrossRefGoogle Scholar
  49. Nicassio, P. M., Moxham, E. G., Schuman, C. E., & Gevirtz, R. N. (2002). The contribution of pain, reported sleep quality, and depressive symptoms to fatigue in fibromyalgia. Pain, 100, 271–279. doi: 10.1016/S0304-3959(02)00300-7 PubMedCrossRefGoogle Scholar
  50. Okifuji, A., & Hare, B. D. (2011). Nightly analyses of subjective and objective (actigraphy) measures of sleep in fibromyalgia syndrome: What accounts for the discrepancy? Clinical Journal of Pain, 27, 289–296. doi: 10.1097/AJP.0b013e31820485db PubMedCentralPubMedCrossRefGoogle Scholar
  51. Osorio, C. D., Gallinaro, A. L., Lorenzi-Filho, G., & Lage, L. V. (2006). Sleep quality in patients with fibromyalgia using the Pittsburgh Sleep Quality Index. The Journal of Rheumatology, 33, 1863–1865.PubMedGoogle Scholar
  52. Paller, C. J., Campbell, C. M., Edwards, R. R., & Dobs, A. S. (2009). Sex-based differences in pain perception and treatment. Pain Medicine, 10, 289–299. doi: 10.1111/j.1526-4637.2008.00558.x PubMedCentralPubMedCrossRefGoogle Scholar
  53. Pigeon, W. R., Moynihan, J., Matteson-Rusby, S., Jungquist, C. R., Xia, Y., Tu, X., et al. (2012). Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: A pilot study. Behaviour Research and Therapy, 50, 685–689. doi: 10.1016/j.brat.2012.07.005 PubMedCentralPubMedCrossRefGoogle Scholar
  54. Prados, G., & Miró, E. (2012). Fibromialgia y sueño: Una revisión [Fibromyalgia and sleep: A review]. Revista de Neurología, 54, 227–240.PubMedGoogle Scholar
  55. Rivera, J., & González, T. (2004). The Fibromyalgia Impact Questionnaire: A validated Spanish version to assess the health status in women with fibromyalgia. Clinical and Experimental Rheumatology, 22, 554–560.PubMedGoogle Scholar
  56. Royuela, A., & Macías, J. A. (1997). Propiedades clinimétricas de la versión castellana del cuestionario de Pittsburgh [Clinimetrical properties of the Spanish version of the Pittsburgh questionnaire]. Vigilia-Sueño, 9, 81–94.Google Scholar
  57. Russell, I. J., & Larson, A. A. (2009). Neurophysiopathogenesis of fibromyalgia syndrome: A unified hypothesis. Rheumatic Diseases Clinics of North America, 35, 421–435. doi: 10.1016/j.rdc.2009.06.005 PubMedCrossRefGoogle Scholar
  58. Rutledge, D. N., Jones, K., & Jones, C. J. (2007). Predicting high physical function in people with fibromyalgia. Journal of Nursing Scholarship, 39, 319–324. doi: 10.1111/j.1547-5069.2007.00187.x PubMedCrossRefGoogle Scholar
  59. Salaberría, K., Páez, D., & Echeburúa, E. (1996). Evaluación de la validez del cambio inducido por los tratamientos psicológicos [Assessment of the validity of change induced by psychological treatments]. Boletín de Psicología, 52, 71–96.Google Scholar
  60. Sánchez, A. I., Díaz-Piedra, C., Miró, E., Martínez, M. P., Gálvez, R., & Buela-Casal, G. (2012). Effects of cognitive-behavioral therapy for insomnia on polysomnographic parameters in fibromyalgia patients. International Journal of Clinical and Health Psychology, 12, 39–53.Google Scholar
  61. Smets, E. M., Garssen, B., Bonke, B., & De Haes, J. C. (1995). The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. Journal of Psychosomatic Research, 39, 315–325. doi: 10.1016/0022-3999(94)00125-O PubMedCrossRefGoogle Scholar
  62. Spaeth, M., Rizzi, M., & Sarzi-Puttini, P. (2011). Fibromyalgia and sleep. Best Practice & Research Clinical Rheumatology, 25, 227–239. doi: 10.1016/j.berh.2011.03.004 CrossRefGoogle Scholar
  63. Stuifbergen, A. K., Phillips, L., Carter, P., Morrison, J., & Todd, A. (2010). Subjective and objective sleep difficulties in women with fibromyalgia syndrome. Journal of the American Academy of Nurse Practitioners, 22, 548–556. doi: 10.1111/j.1745-7599.2010.00547.x PubMedCrossRefGoogle Scholar
  64. Sullivan, M. J. L., Bishop, S., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation. Psychological Assessment, 7, 524–532. doi: 10.1037/1040-3590.7.4.524 CrossRefGoogle Scholar
  65. Tang, N. K. Y. (2009). Cognitive-behavioral therapy for sleep abnormalities of chronic pain patients. Current Rheumatology Reports, 11, 451–460. doi: 10.1007/s11926-009-0066-5 PubMedCrossRefGoogle Scholar
  66. Theadom, A., Cropley, M., & Humphrey, K. L. (2007). Exploring the role of sleep and coping in quality of life in fibromyalgia. Journal of Psychosomatic Research, 62, 145–151. doi: 10.1016/j.jpsychores.2006.09.013 PubMedCrossRefGoogle Scholar
  67. Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine, 5, 355–362.PubMedCentralPubMedGoogle Scholar
  68. Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P., et al. (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care and Research, 62, 600–610. doi: 10.1002/acr.20140 PubMedCrossRefGoogle Scholar
  69. Wolfe, F., Smythe, H. A., Yunus, M. B., Bennet, R. M., Bombardier, C., Goldenberg, D. L., et al. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism, 33, 160–172. doi: 10.1002/art.1780330203 PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • M. Pilar Martínez
    • 1
  • Elena Miró
    • 1
  • Ana I. Sánchez
    • 1
  • Carolina Díaz-Piedra
    • 1
  • Rafael Cáliz
    • 2
  • Johan W. S. Vlaeyen
    • 3
  • Gualberto Buela-Casal
    • 1
  1. 1.Facultad de PsicologíaUniversidad de GranadaGranadaSpain
  2. 2.Rheumatology ServiceVirgen de las Nieves University HospitalGranadaSpain
  3. 3.Faculty of Psychology and Educational Sciences, Research Group Health PsychologyUniversity of LeuvenLeuvenBelgium

Personalised recommendations