Best Practice & Research Clinical Rheumatology

Vol. 17, No. 4, pp. 649 665, 2003

doi:10.1016/S1521-6942(03)00034-2, www.elsevier.com/locate/jnlabr/yberh

Psychological and behavioural therapies

in fibromyalgia and related syndromes

David A. Williams* PhD

Associate Professor of Medicine

University of Michigan, Room 5510D, MSRB-1, 1150 W. Medical Center Dr., Ann Arbor, MI 48109-0680, USA

Psychological and behavioural therapies are being applied to patients with fibromyalgia (FM) with
increasing frequency. The rationale for including psychological therapies is not for the treatment
of co-morbid mood disorders, but rather to manage the many non-psychiatric psychological and
social factors that comprise pain perception and its maintenance. This chapter reviews the
involvement of mental health professionals under both the biomedical and biopsychosocial
models of illness and describes cognitive behavioural therapy (CBT), a commonly used form of
psychological therapy in the management of chronic pain conditions. The empirical literature
supports the use of CBT with FM in producing modest outcomes across multiple domains,
including pain, fatigue, physical functioning and mood. Greatest benefits appear to occur when
CBT is used adjunctively with exercise. While the benefits are not curative or universally
obtained by all patients, the benefits are sufficiently large to encourage future refinement of CBT
for this population of patients.

Key words: cognitive behavioural therapy (CBT); fibromyalgia; behavioural medicine;

psychological treatment; biopsychosocial.

A CLASH OF MODELS FOR UNDERSTANDING UNEXPLAINED PAIN

Patients suffering from fibromyalgia (FM) experience a variety of physical symptoms (e.g.
pain, fatigue, tenderness and sleep disturbance), decrements in physical functioning and
disruptions in psychological functioning (e.g. memory problems, diminished mental
clarity, mood disturbances and lack of well-being). The aetiology of FM is still unknown1
and treatment approaches are based largely upon pharmacological management of
symptoms. Treating FM by this approach benefits less than 50% of patients2 and even
fewer achieve lasting improvements in functional status (e.g. 12%).3
Psychological and behavioural therapies are often used to augment symptom
management but the rationale for including these therapies varies depending upon the
model of illness by which FM is viewed. The biomedical model recruits mental health
professionals to address the psychiatric aspects of FMsuch as depression,
somatization disorders or anxiety disordersafter attempts to cure the presenting
symptoms have failed. The biopsychosocial model4 includes mental health professionals

* Tel.: 1-734-647-2010; Fax: 1-734-763-2025.

E-mail address: daveawms@umich.edu (D.A. Williams).

1521-6942/03/$ - see front matter Q 2003 Elsevier Science Ltd. All rights reserved.
650 D. A. Williams

from the outset, but not because FM or chronic pain is a psychiatric disorder.
Supported by over 30 years of research5, the biopsychosocial model does not draw
clear distinctions between the biological and psychological properties of pain. The
perception of pain is an integration of both properties, and successful treatments
acknowledge this integration.6 In this model, an initial complaint such as pain or fatigue
can arise from multiple sources (e.g. trauma, disease, medical procedures, congenital
defects, etc.). Integrated biological and psychosocial processes then facilitate the
maintenance of the complaint. For example, an increase in neurally mediated
nociceptive activity (biological change) can lead to increases in anxiety (psychological
change) and to decreases in physical activity such as exercise (social/behavioural
changes). The resulting experience of increased pain is inextricably produced by all
elements of the biopsychosocial model, not just the nociceptive activity.
The biopsychosocial model is considered a particularly useful model for under-
standing rheumatological illnesses7,8 as it can guide rational approaches to treatment,
even when aetiologies are vague, without resorting to psychiatric labelling. The model,
however, must overcome many barriers before integrated treatments can be applied
broadly and practically. For example, patients familiar with the biomedical model resist
the suggestion that psychological factors influence their pain, and misinterpret the
involvement of mental health professionals as a sign they have been de-legitimized.
Patients voice this concern on credible grounds given the medical community, the legal
community and the insurance industry continue to use dualistic conceptualizations of
illness despite supporting evidence of the biopsychosocial perspective. For the
biopsychosocial model to gain broader acceptance, evidence-based education is needed
on how psychosocial factors affect pain conditions, what psychological and behavioural
therapies directly address psychosocial issues and, finally, a balanced analysis of the
evidence supporting the use of these interventions for conditions such as FM. This
chapter addresses each of these issues and attempts to highlight both the advantages
and limitations of using psychological and behavioural approaches in FM management.

PSYCHOSOCIAL FACTORS AND FIBROMYALGIA

Two individuals can experience identical pain-evoking events yet experience and
respond to the pain in markedly different ways. This fascinating observation underlies
why the work on the appraisal process9 is so often considered relevant when trying to
understanding psychological processes that help to determine the perception of pain.
This theory posits that once a nociceptive event occurs, individuals make an appraisal of
the event. Primary appraisal determines whether the nociceptive event is harmful,
threatening or of some benefit. If judged harmful or threatening, a secondary appraisal
helps to determine whether sufficient resources exist to adequately control and deal
with the nociceptive event. If resources are adequate, appropriate coping can
commence and the pain experience can diminish. If resources are judged as inadequate,
affective responses such as anxiety or depression may further exacerbate the
perception of pain, leading to potentially maladaptive responses such as isolation and
social withdrawal, diminished self-efficacy to utilize healthy behaviours (e.g. healthy diet,
exercising) and the adoption of global beliefs that can diminish the potential of
successfully managing persistent illnesses (e.g. learned helplessness or an external locus
of control). Thus, failure at this secondary level of appraisal to perceive sufficient coping
resources to manage pain or illness can result in perceptions and behaviours that
promote the transition from acute to chronic pain.10
 Psychological and behavioural therapies 651

Perceived lack of coping resources

Successful management and/or resolution of pain and functional limitations are more
likely if patients believe that they possess adequate knowledge and skills to deal
effectively with their illness. For some patients, secondary appraisal reveals that they
lack the necessary skills for coping (e.g. the ability to use exercise to maintain functional
status, the ability to confide in others when pain gets intense, the ability to rely on
oneself to reduce tension or management stress, or the ability to find the right
physician who will manage pain in a mutually agreeable manner). For these patients,
incomplete and insufficient forms of coping may fill the void otherwise occupied by sets
of adaptive skills (e.g. catastrophic thinking). Studies of rheumatological pain (i.e.
osteoarthritis) suggest that even if coping skills are initially missing, they can be rapidly
taught to patients. After such training, patients show significant improvements in pain
and physical disability, as well as decreases in catastrophic thinking.11 In patients with
FM, coping skills training has also been associated with improved pain and functional
status12,13 and is therefore a common emphasis of psychological and behavioural
interventions.

Anxiety and depression

When secondary appraisal concludes that coping resources are inadequate, anxiety or
depression can result. These changes in mood need not be at pathological levels (i.e.
sufficient to lead to the clinical diagnosis of depression or anxiety) in order to influence
pain perception. Evidence from brain imaging data suggests that the afferent central
processing of pain is highly dependent upon even subclinical psychological factors to
produce the experience of pain.14 When mood disorders co-exist with pain, the effect
upon pain perception would be expected to be even greater.

Depression
Depression has 1.6 2.9% prevalence in community samples.15 In a review of prevalence
rates of depression in rheumatological samples, the rate was between 14 and 23% for
arthritic groups and ranged between 26 and 71% for FM.16 Community samples of FM
tend to show lower rates while tertiary care samples tend to show higher rates of co-
morbid psychiatric disorders.17 The higher level of psychiatric co-morbidity in FM has
led some clinicians to suggest that FM is simply a variant of psychiatric illness.18
However, sufficient differences in the clinical presentations of these illnesses has led
others to conclude that FM and depression are distinct but frequently co-occurring
entities that require separate interventions.19,20 For example, the type of depression
most commonly seen in FM is not the hallmark melancholic form of depression but
rather an atypical variant in which symptoms are opposed to what would be expected.
This type of depression occurs in only 22% of major depression cases.21 In atypical
depression, sleep onset is delayed but total sleep time is increased, appetite is increased
and moods are reactive rather than flat (especially anxiety reactions).22 Further,
depression in chronic pain conditions (including FM) is frequently a reaction to pain
rather than its cause. In an extensive review of this topic, 33 studies were examined that
supported one of the following: (a) antecedent hypothesis (depression precedes pain),
(b) the consequence hypothesis (depression follows pain), or (c) the scar hypothesis
(depression predisposition predisposes one to develop pain). The conclusion of the
review was that when depression and pain co-existed, depression was most frequently
652 D. A. Williams

the consequence of having pain rather than its initial cause.23 In aggregate, the literature
on both FM and pain in general suggests that when depression is co-expressed with FM,
it needs to be treated in addition to, but not in place of, FM.

Anxiety
Anxiety has been well studied as an emotion that influences the perception of acute
pain, as it tends to lower both pain threshold and tolerance.24 While the point
prevalence of an anxiety disorder in the general population is 7%, anxiety disorders
such as panic disorder and post-traumatic stress disorder are being increasingly
identified as co-morbid psychiatric concerns in patients with chronic pain.25 As anxiety
disorders have received significantly less research attention than depression in chronic
pain, it is not known how much of the co-morbidity is an artifact of studying these
phenomena in tertiary care settings.

Responses limiting adaptation

Diminished social support

If a patients secondary appraisal process reveals that coping resources are inadequate
(e.g. he/she lacks a plan for how responsibilities can be met in the face of pain),
individuals may either withdraw socially or becoming solicitous of help and comfort
from others. Neither response is uniformly adaptive (i.e. in the patients best interest in
the long term). Temporarily withdrawing to diminish demands from others and re-
group mentally may be adaptive if this provides opportunities to privately work out
solutions leading to better functioning and quality of life. Withdrawing in the long term,
however, may be maladaptive. Longitudinal studies of pain link poor social support with
a poor prognosis; this poor social support may either occur as a reaction to pain or
antedate these symptoms.26 Asking for help may be unnatural to many individuals with
FM but the bulk of the literature in this area suggests that there are many benefits to
reaching out to others. Social support offers not only emotional comfort but is also a
source of knowledge for developing additional coping skills and a source of
reinforcement for maintaining difficult behavioural programmes designed to promote
health (e.g. exercise, diet). In general, social support positively affects pain manage-
mentbut only if that support is perceived as wanted and of good quality.27

Diminished self-efficacy
After secondary appraisal reveals that coping resources are available, the individual
must make yet another decision regarding ones personal ability to take advantage of
adaptive resources. Self-efficacy beliefs represent ones perceived ability to perform a
specific task in order to achieve a specific outcome. For example, a patient might
strongly believe that she can successfully exercise for 20 min without a flare of
symptoms while holding a second self-efficacy belief that she can type for 10 min
without a setback. Beliefs in self-efficacy may or may not reflect actual ability, but
perception of self-efficacy influences choices, decisions and responses to options that
can determine the course of an illness.28 In rheumatological studies, improvements in
self-efficacy were highly predictive of improvements in pain, depression and health
status.29 Several studies of FM which used both exercise and cognitive behavioural
therapy were helpful in improving this set of beliefs.30,31
 Psychological and behavioural therapies 653

External locus of control, lack of control and learned helplessness

Related to self-efficacy beliefs are more global beliefs in personal ability to affect
outcomes. Beliefs in personal control evolve from multiple learning experiences where
personal effort is believed to affect outcomes. The belief in personal control has been
labelled an internal locus of control. Alternatively, an external locus of control is
learned when outcomes are perceived as occurring outside personal control. In studies
of patients with chronic pain and rheumatological conditions, a stronger belief in
internal locus of control for pain control has been repeatedly associated with lower
levels of physical and psychological symptoms, and with better response to
therapy.32 34 In studies of patients with FM, internal locus of control has been
associated with better affect, reduced symptom severity and less functional
disability.35,36 Most patients with FMS, however, are more external in their locus of
control compared with other rheumatological conditions or with patients with other
chronic pain conditions.35,37,38 This belief and a belief in learned helplessness that can
evolve following failed attempts at self-management diminishes motivation to take
personal responsibility for managing illnesses. Thus, this psychosocial factor represents
a highly important target for treatment.

WHAT IS COGNITIVE AND BEHAVIOURAL THERAPY?

Origins and rationale for use in FM

Cognitive behavioural therapy (CBT) has its origins within the traditional psychother-
apy literature and is considered an efficacious treatment for depression and anxiety.39
Each application of CBT (e.g. for depression or anxiety) uses a different set of specific
skills, but each of the skills shares a common scientific foundation based on learning and
cognitive principles.40 The techniques used to change behaviour are based on principles
of classical and operant conditioning (e.g. extinction, positive and negative
reinforcement, shaping, prompts), and observational learning. The techniques used
to produce cognitive changes are based largely on the development of problem-solving
skills and the principles of attributional change.
The principles underpinning cognitive and behavioural change are not limited in
application to psychiatric conditions, and therefore these same principles have been
used to promote adaptation to medical conditions as well (e.g. coronary disease41,
cancer survival42 and chronic pain6). In a recent review of 25 CBT trials for chronic pain,
this intervention was credited with producing significant improvements across multiple
relevant outcome domains, including pain symptoms.43 Numerous studies have
similarly applied CBT to rheumatological conditions such as osteoarthritis (OA) and
rheumatoid arthritis (RA) with success.44 Given the pre-eminence of pain symptoms in
FM, and the success of CBT in managing other forms of chronic pain, its application to
FM was a rational advancement.

All CBT is not alike

Over the past 10 years, a number of treatment trials have explored the usefulness of
CBT for managing FM. To date, it has been difficult to evaluate the collective results
of these studies because each study used a different set of skills, different labels for
treatment, differing formats of treatment (e.g. group/individual, duration, skill level
654 D. A. Williams

of therapist) and differing domains of outcomes to evaluate the efficacy of treatment.

The commonality of these trials, however, was that the sets of skills used in treatment
were based on, and supported by, the scientific principles of learning and cognitive
change. Thus, CBT-supported interventions typically include three phases: (1) an
educational phasein which patients are familiarized with a model for understanding
their pain (e.g. the biopsychosocial model), (2) a skills training phasein which training
is provided in a variety of cognitive and behavioural pain-coping skills (e.g. relaxation
training, activity pacing, pleasant activity scheduling, problem-solving, sleep hygiene),
and (3) an application phasein which patients learn to apply their skills in
progressively more challenging real-life situations.45

What skills are useful in addressing the psychosocial factors of FM?

Education
Education is commonly used to provide a common foundation for understanding how
and why self-management skills can be helpful in managing pain and illness. Common
examples of educational topics include background on what is known about pain and
FM, what interventions are useful and why, the gate control theory of pain46, and the
biopsychosocial model.4

Pain-coping skills
While there are many coping skills that have been used in the studies of psychological
and behavioural therapies for pain and FM, the following is a partial list of some of the
more commonly taught skills.

Time-based pacing skills/graded activation

Many patients unknowingly worsen their chronic pain or other symptoms because,
when they have a good day, they attempt to do more than they are capable of doing
which leads them to having several bad days of symptom flares. This tendency to be
intermittently active accentuates the normal waxing and waning course of chronic pain
and is a source of frustration for patients when they cannot predict what they will be
able to do from one day to the next. Time-based pacing is a method that can be used to
improve physical functioning while minimizing the likelihood of flare-ups of pain or
fatigue. This approach has been successfully applied with low-back populations47,
rheumatological populations48 and in patients having chronic fatigue syndrome.49 The
key to this skill is to limit activities based upon time rather than upon patients
subjective experience of pain or fatigue. The time can be as short as several minutes or
as long as several hours, depending upon what the patient can initially tolerate without
exacerbation. Once this time-based activity programme is in place, the therapist and
the patient work together to develop a plan that achieves goals, which are mutually
agreed upon for gradually increasing the amount of time spent on specified targeted
behaviours (i.e. graded activation). Graded activation programmes emphasize short
activity followed by a short rest. Such slowly advancing programmes have the tendency
to improve functional status over time, along with either stable or improved levels of
symptoms (e.g. pain, fatigue).

Pleasant activity scheduling

Pleasant activity scheduling is a complementary skill taught with time-based pacing50 in
which patients learn to broaden their range of pleasurable activities by scheduling them
 Psychological and behavioural therapies 655

into their routine. Scheduling is preferable to spontaneity because pain and fatigue tend
to reduce spontaneous pleasurable activity. Gradually expanding the ability of patients
to function and exposing them to new pleasurable activities promotes positive affect,
new opportunities for social interaction, and confidence in the bodys ability to function
at a higher level, which, in turn, can enhance self-efficacy and a sense of control over
pain.

Problem-solving skills and assertiveness training

Having chronic pain or a chronic illness presents problems that most healthy individuals
never need to address. Programmatic problem-solving strategies can be taught to
patients and can help to break large problems down into solvable pieces.51 What is
taught in therapy is a strategy for solving problems, not solutions to individual
problemsthus giving patients a tool that can be carried into the future. When applied
successfully, patients learn methods to overcome barriers to improving function and
attain a greater sense of control over the process of adapting to a chronic illness.
Problems of an interpersonal nature are common in patients with FM. Assertive
communication skills training52 can assist patients in obtaining the type of assistance or
social support they desire in their attempts to improve functional status. Success in
problem solving or assertiveness can, in turn, enhance ones self-efficacy for self-
management of illness.

Relaxation skills
The relaxation response (i.e. personal control over obtaining both physiological and
mental relaxation) has strong support as a method for managing pain and insomnia,
and can lead to improved functioning and concentration.53 While there is no
consensus as to the best method of teaching the relaxation response (e.g.
progressive muscle relaxation, visual imagery, hypnosis, biofeedback), all appear to
offer equally useful modalities for learning this response. The relaxation response is
perhaps the single most studied CBT skill for the management of pain. The
relaxation response is also frequently embedded in therapies labelled as stress-
management classes, although these classes may also include time-management and
affect-management skills as well.

Sleep hygiene
Sleep disturbances are common in patients with FM. Behavioural strategies that focus
on improved sleep (e.g. onset, maintenance, quality) can help individuals to get needed
restorative sleep with additional benefits in improved mood, better management of
pain, less fatigue and improved mental clarity.54 Sleep hygiene strategies tend to focus
on timing strategies (e.g. having regular sleep routines), sleep behaviours (e.g.
attempting to sleep only when in need of sleep), and behavioural avoidance of
stimulating activities before bed, such as emotionally charged conversations, watching
action movies, or consuming nicotine or caffeine.

Attributional change
While it is difficult to demonstrate that a thought precedes an emotion, this assumption
underpins much of the work on cognitive change. As described, perceptions of threat
or vulnerability produce a cascade of affective and behavioural responses that can harm
the long-term adaptation to illnesses. Attributional change is best elicited by exposing
patients to real-life learning opportunities where they can perceive success associated
with changes in behaviour. Four types of experience are recommended: (1) mastery
656 D. A. Williams

experiencessuch as actually trying many of the coping skills just described, (2)
modellingwatching a trusted other person experience success or give testimonial of
success, (3) social persuasionhaving a trusted other person convince patients of the
benefits of a technique, or (4) physiological feedbackgathering indirect evidence of
benefits (e.g. biofeedback, monitoring records of physiological changes).55

Relapse prevention
Teaching coping skills is only the first step in a successful application of CBT. Not only
must the skills be taught and comprehended, they must be practiced and used over time
as well. For this reason, little improvement is to be expected immediately following the
teaching of skills. Most benefits are noted 3 6 months after the skills have been applied
and incorporated into the lives of patients. The gains achieved in CBT are more likely to
be durable than those seen in other types of therapy; it is common for individuals who
attend CBT programmes to develop improvements for a year or more after initial
therapy, even when these programmes are quite brief and especially if changes in
attributions are achieved. For behavioural changes, reminders or boosters should be
included in the treatment plan so that patients maintain the use of the skills they have
learned.

EVIDENCE SUPPORTING THE USE OF CBT IN FIBROMYALGIA

Due to differences in nomenclature, many more studies than those claiming to have
used CBT have taught skills to patients with FM that are based upon principles of
behavioural and cognitive change. Referred to here as CBT-supported skills, the next
section briefly reviews 17 clinical studies fitting this classification. It should be noted
that, based on its theoretical tie to the biopsychosocial model, CBT as applied to
medical conditions tends not to be used as a stand-alone intervention but rather as a
companion to other physical modalities. The most common companions of CBT are
pharmacological management strategies and exercise. The next section summarizes
the CBT treatment literature for FM under four categories: (a) interventions in which
CBT-supported skills are studied as single modalities, (b) studies in which CBT-
supported skills are combined with other non-pharmacological interventions, (c)
studies of CBT-supported skills showing no incremental benefit over other non-
pharmacological interventions, and (d) studies supporting the benefits of combining
CBT with exercise.

Studies supporting the use of single modality CBT in isolation

One of the earliest studies of a behavioural intervention for FM involved the use of
Electromyography (EMG) assisted relaxation training (i.e. biofeedback).56 In this small
experimental study, six patients were trained in progressive muscle relaxation. The
effectiveness of patients attempts to relax was verified and reinforced using
biofeedback for 15 twice-weekly sessions. The control group for the study received
sham biofeedback where random feedback negated any reinforcement that would have
contributed to the learning of the relaxation response. Six subjects participated in this
condition for the same duration of time. Analyses between groups were not reported,
but prepost-treatment improvements in visual analogue scale (VAS) pain and morning
stiffness were realized only by the accurate biofeedback condition. Both groups showed
 Psychological and behavioural therapies 657

an improvement in tender-point counts, suggesting that simple attention (contained in

both forms of biofeedback) might help to improve tender points.
Two studies coming from the same working group have suggested that stress-
reduction techniques (based largely on relaxation) can benefit patients with FM.
The first was a single-group design that taught CBT-supported stress-reduction
techniques to FM patients in 10 weekly 2-h sessions.57 By using stress-reduction
strategies, FM patients gained a 20% improvement in control over pain and
substantial reductions in a variety of distress indicators. In a similar study, 42
patients were offered the same stress-management programme, 18 were assigned
to a wait list control group, and 24 were randomly selected from FM patients
showing no interest in the stress-management programme. Results indicated that
the stress-management programme showed significant reduction in pain ratings,
whereas the other two groups failed to realize the same benefit in the same time
period.58
In a study that isolated the effects of relaxation from a mixed grouping of skills,
relaxation by itself failed to show benefits. This study combined education, pain-coping
skills (including relaxation), social support and exercise into 15 weekly 2-h group
sessions. The comparison group received only relaxation training in 15 weekly 50-min
sessions. Each group contained 16 patients, and treatment success was determined on
the basis of showing improvements in three of six potential outcome measures (i.e.
medication use, physical therapy use, sleep improvement, global impression of change,
symptoms checklist or pain rating). Thirty-one percent of the mixed-skills-therapy
group met the criterion for success whereas 0% of the relaxation-only group met this
same criterion.59

Comment
While relaxation appears to be an important component of biopsychosocially driven
therapy, its primary impact in these three studies with FM patients was to produce
modest decreases in pain. While this outcome is encouraging, it was not without a great
deal of therapist and patient time to achieve this outcome. Broader outcomes may be
possible when relaxation is contained within a multi-modal framework rather than as a
stand-alone intervention.

Studies supporting multi-disciplinary use of CBT

In a study that applied CBT within the context of a large multi-disciplinary pain
programme, 48 participants were given an intervention consisting of education, physical
therapy, occupational therapy and CBT-supported pain management skills. Delivered in
a brief format consisting of three half-day sessions in the first week followed by one half-
day session during weeks 2 6 (i.e. a total of six half-day sessions), this overall
programme found significant improvements in pain ratings, distress and functional
disability.12 No control group was used in providing these findings; however, from a
biopsychosocial perspective, this intervention appears to have covered many of the
relevant areas of concern under this model.
A second study of education, relaxation and qigong movement therapy was applied
to 20 FM patients for 2.5 h for 8 consecutive weeks. As in the previous study, a broad
range of outcomes appear to have improved, including pain, fatigue, sleep, mood and
general health at the conclusion of 8 weeks. However, as in the previous study, these
658 D. A. Williams

findings were not compared with a control group, thus limiting the interpretation of
whether these improvements were due solely to the therapy programme.60
One of the first studies to demonstrate the long-term benefits of CBT-supported
interventions was published in two reports. Patients with FM attended an inpatient
programme that included CBT-supported skills in relaxation, coping skills, pacing and
exercise. This single-group study found significant improvements in pain, pain
behaviours, control over pain, and distress in the 25 individuals receiving this treatment
after 3 months.13 In a 30-month follow-up report, the effects of this intervention
appeared to be robust, with 22 of the original 25 patients showing maintenance of
treatment gains.61 Again, while the findings of these two studies are encouraging,
interpretation is limited given the lack of a control group.
A multi-disciplinary intervention using CBT that did use a control group offered
CBT-supported skills in the context of education, behavioural modification, stress
management, instructions in fitness and social support. The frequency of these sessions
was 24 90-min group sessions. One hundred and four patients participated in the
programme, with 70% achieving reductions in tender-point counts below 11, and
improvements on the FM impact questionnaire (FIQ) of at least 25%. While this was not
a randomized trial, a comparison group of FM patients who did not participate in the
group failed to show any of the programmes benefits. In addition, 33 group participants
who were followed for 2 years continued to show benefits from the programme,
supporting the robust effects of the programme.62
One of the most recent studies of CBT is one in which standard pharmacological
symptom management in combination with instruction in exercise was compared with
the same standard care conditionbut to it was added six 1-h group sessions of CBT
targeting improvements in functional status.3 At 12 months post-treatment, significant
improvements in self-reported physical functional status were realized by 25% of the
patients receiving the additional CBT, but only 12% of the patients receiving standard
care achieved the same benefit in function. The authors concluded that the addition of
six brief sessions of CBT to standard care can more than double the number of patients
who can receive clinically relevant benefits in functional status. The authors also noted
that 75% of the patients receiving CBT failed to gain lasting improvements in functional
status, suggesting that the form of CBT used in this study worked extremely well for a
subgroup of patients but not for all.

Comment
Many of the multi-modal and multi-disciplinary studies of CBT have reported
benefits when CBT was added to treatment, but the specific incremental effect of
adding CBT is difficult to discern. Studies either fail to include a no-treatment
control group, fail to dismantle the CBT components from other components, or fail
to control for differences in therapist attention across treatments of differing
duration. Several studies have designs that permit better comparisons of incremental
effects of CBT; these are reviewed in the next two sections. Some studies have
found no incremental benefits while others have found synergistic benefits of
combining CBT and exercise.

Studies supporting no incremental benefit of CBT beyond other therapies

One of the few studies to focus on social support compared a mixed set of CBT-
supported skills (i.e. education, relaxation, behavioural pacing, social support) with
 Psychological and behavioural therapies 659

a purely education group that also included social support.63 Both interventions were
delivered in 90-min group sessions over a 10-week period. Sample sizes for the CBT-
supported group and the education/support group were 48 and 38, respectively. At 6
months follow-up, both treatment groups demonstrated improvements in pain
behaviour, depressive symptoms, myalgic scores, helplessness and coping. Thus, in
this study, similar types of improvement were noted whether CBT-supported skills
were present or not. This study draws into question the incremental utility of the CBT-
supported skills used in this study (i.e. pacing, relaxation) while highlighting the potential
importance of social support.
In a well-controlled study, 49 patients were assigned to an education/exercise/cog-
nitive skills group that met for 12 sessions in 6 weeks. This was compared with an
education/exercise group that was devoid of the cognitive skills component n 39:
Finally, a third group was a wait-listed control group n 43: Comparisons between
baseline and 12-month follow-up revealed within-group improvements over 12 months
for both treatment groups on pain coping and pain control, but no between-group
differences for the active treatment groups were noted. The authors concluded that
cognitive skills added little to the outcomes while increasing the therapy burden for staff
and patients and increasing the costs.64 It should be noted, however, that failure to
achieve better results in the cognitive group could have been due to the unusually low
educational level of patients used in this study. Additionally, compliance in the group
receiving cognitive skills was also low, drawing into question whether the active
intervention was delivered as intended.
A third study examined the differential benefits of aerobic exercise and CBT-
supported stress management.65 The aerobic exercise group consisted of 42 45-min
sessions over 14 weeks that had patients achieve 60 75% of their maximal heart rate.
Twenty subjects were in this condition. Stress management was delivered to 20 patients
in 20 90-min sessions spaced as follows: twice weekly for 6 weeks then once weekly for
8 weeks. This study also utilized a standard care control condition in which 20 patients
participated. Pain report (VAS) and tender-point count was improved in both the
exercise and stress-management groups compared with the standard care control
group. Additionally, exercise was better than stress management in improving measures
of fatigue and work capacity, whereas stress management was better than exercise for
symptoms of depression. In this study, short-term improvements failed to be
maintained over the 4-year follow-up; however, like the previous study, compliance
with the behavioural interventions was reported as problematic.

Studies supporting the benefits of combined exercise and CBT

One of the earliest studies to support the combined use of CBT-supported skills with
exercise was a single group design that followed 16 patients through a 10-session
intervention. The intervention consisted simply of cognitive problem-solving skills and
exercise. Reductions in reported pain were noted immediately post-treatment and at 6
months, as were positive adjustments to lifestyle.66
A second study in this category compared an exercise/education intervention with a
waiting list control condition.67 The exercise consisted of two exercise classes in which
patients reached 60 75% of their maximal heart rate combined with 12 group sessions
covering a variety of educational and CBT-supported skill topics. These educational
sessions met twice weekly for 6 weeks. Compared with the wait-list control group, the
treated group showed improvements in fatigue, physical movement and well-being after
just 6 weeks. Long-term data were not available for this study.
660 D. A. Williams

In a more recent study, 37 patients were offered aquatic-based exercise therapy

plus education.68 Pool-based exercise was offered for 35 min for 24 weekly
sessions. In addition to exercise, all subjects also received six 1-h educational
sessions that included CBT-supported skills in coping and lectures on the benefits
of activity. The control sample for this study was a group of 32 patients receiving
standard medical care for FM. After 6 months, significant differences were noted
between the groups on measures of pain, physical functioning, grip strength,
walking ability, anxiety and depression, and the total (FIQ). While the results of this
controlled study are quite positive for the patients who remained in the study, it
should be noted that, like the other studies involving exercise, adherence was
problematic, with 24% of the exercise/education group dropping out of treatment
before its completion.
In a study that recruited a particularly challenging sample of patients with FM, an
intervention labelled educationthat included knowledge about FM and CBT-
supported coping skills training, such as relaxationwas compared with the same
education group plus aerobic exercise or with a delayed treatment control group.31 The
education/CBT condition was delivered over 6 weeks in six 90-min group sessions, and
the combination education/exercise group added an additional 1 h week of exercise.
The study sample was particularly challenging as 25% of the patients were severely
depressed at baseline and 62% were sick-listed. Outcomes that tend to improve in
other studies (e.g. pain and function) did not show improvement in this study of
extremely disabled patients. What did change, however, was self-efficacy to improve
pain and function as well as quality of life. Both groups, but in particular the combination
group, appeared to have provided sufficient learning and success experiences to
improve self-efficacy, a difficult yet necessary first step in a behavioural programme of
this nature. With such an extremely debilitated sample, a much longer course of
treatment may have been necessary to see the more global improvements found in
other studies.
In perhaps the most complex design to date in this area, FM patients were randomly
assigned to one of four groups: (1) biofeedback (cognitive and muscular relaxation)
delivered to 29 patients in six individual training sessions over 6 weeks, (2) exercise
(strength, mobility, endurance) for 30 patients with session frequency matched to
biofeedback, (3) a combination of biofeedback and exercise for 30 patients with timing
matched to the other two groups, and (4) an educational/attentional control group
(with no cognitive problem-solving) for 30 patients with timing matched to the other
three groups30. In this study, all three groups produced improvements in self-efficacy to
control pain and improve function. Tender-point counts also improved for all three
groups. The exercise-alone and the combination group demonstrated additional
benefits in physical functioning. Longer term (e.g. 2 years), the combination group
demonstrated the best maintenance of gains in tender-point count, improvements in
physical functioning, and improvements in self-efficacy. In contrast, the educational
control group not only failed to share in these improvements but actually deteriorated
over time.

Practice issues learned from the empirical studies

As is evident from the literature cited, CBT can be composed of many different skills
that can be offered alone or in combination with other skills, in group or individual
formats, in varying durations of treatment and with varying outcomes targeted. While
there is little agreement over what skills should be included in a CBT intervention for
 Psychological and behavioural therapies 661

FM, there is some evidence that CBT works better when specific outcomes are
targeted and skills are selected that specifically address those targets. In one study that
compared targeted versus non-targeted outcomes for FM, only the outcomes that
were specifically tied to CBT content (i.e. targeted) demonstrated sustained change.13
A similar finding was noted in a second study that specifically targeted improvements in
functional status.3
The existing literature also demonstrates that positive outcomes were obtained
with CBT when as many as 24 or as few as six sessions are used.12,62 It is likely
that, in more debilitated populations, greater numbers of sessions are needed if the
content is consistent with what patients are capable of achieving.44 Along these
lines, if patients who receive CBT have a co-morbid mood disorder, or are
receiving disability or compensation, it may be necessary to tailor the programme
to these targets or to ensure that a separate therapist is addressing these issues.
There is also evidence suggesting that positive outcomes are possible when CBT is
delivered in a group format which can be more efficient and less costly than
individual sessions3,8, but individual sessions may be preferable for maximized
tailoring of content or for ensuring that skills are actually being learned and applied
in patients lives.
From the existing literature, it cannot be stated that CBT cures FM, or that all who
receive it will benefit significantly. It does, however, appear that, in this syndrome
characterized by chronic pain and diminished functioningthere is a subset of
individuals who will demonstrate some, or even substantial, improvements if offered
CBT in conjunction with pharmacological management and/or exercise.

SUMMARY

The biopsychosocial model provides a useful framework in which to conceptualize

how FM can be maintained or treated over time. In this model, there is no
predominance of biological or psychological factors but rather a dynamic interplay
of the mind and body. Cognitive factors such as appraisals drive affective and
behavioural responses to illness and help to determine whether adaptation to
illness is consistent or opposed to long-term health. Methods of changing behaviour
and thinking patterns (i.e. CBT skills) have been shown to be effective in improving
health for many mental as well as physical illnesses. The clinical studies of CBT in
FM report more modest improvements than seen with other chronic pain
conditions but generally support the utility of including CBT along with traditional
medical treatment. There is also evidence supporting synergistic benefits of
combining CBT and exercise for FM.
This review found no studies in which CBT failed to produce some form of benefit to
patients with FM, but future studies will also need to identify why some of those
benefits also occurred in other active treatments or control conditions. To integrate
CBT more fully into clinical care, future studies are needed to demonstrate
generalization of treatment effects to population-based samples, explore the underlying
mechanisms of FM and/devise CBT-supported skills that address those mechanisms,
develop better methods of matching skills to patients capabilities, and develop
improved methods of delivering CBT to a broader group of patients on a less costly but
effective basis.
662 D. A. Williams

ACKNOWLEDGEMENTS

Preparation of this manuscript was supported in part by Department of Army Grant

DAMD17-00-2-0018.

Practice points
clinicians need not wait until their treatments have failed before involving
therapists with knowledge of CBT. In fact, brief CBT programmes may be most
effective if implemented early in the course of an individuals illness
CBT should not only be considered when an individual displays some type of
co-morbid psychiatric disorder. In fact, the CBT described in this chapter is not
for depression but for management of the psychosocial factors that can
maintain and exacerbate FM. When depression and FM co-occur, and CBT is
being used to treat depression, it is probably best not to use the same CBT
therapist for both conditions
not all mental health professionals have experience in applying CBT to medical
conditions. Post-doctoral fellowships in behavioural medicine help to train
clinicians with backgrounds in the principles belying CBT to apply their
knowledge towards managing medical diseases
when using CBT, link the CBT skills to specific outcomes
individual sessions offer more intense opportunities for learning and tailoring of
treatment but group sessions offer social support and greater efficiency
monitoring adherence to skills and ensuring that skills are being learned
successfully is essential for determining whether therapy is being used as
intended
teaching skills are not sufficient to ensure that learning has occurred or that
long-term use will continue. Prevention of follow-up relapse is essential

Research agenda
using the biopsychosocial model as a guide, more theoretically based studies
are needed that examine the processes by which changes in psychological and
behavioural factors produce improvements in FM
considerable disability is common in samples of FM. Additional work is needed
on beliefs such as self-efficacy and learned helplessness that can serve as
impediments to successful implementation of cognitive and behavioural
approaches in individuals with these beliefs
current CBT programmes often require substantial human resources in terms
of time and expertise to deliver these therapies. Studies are needed that
explore novel methods of delivering these interventions that make such
interventions more broadly available to the patients who could take advantage
of them
given that different sets of skills appear to be better utilized by some patients
than by others, and that some patients do not appear to benefit at all from such
interventions, additional research is needed to better match patients to the
types of interventions that will be best utilized and most beneficial
 Psychological and behavioural therapies 663

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