Emotional exposure therapy studied for fibromyalgia
WASHINGTON – The use of “emotional exposure therapy,” which addresses unresolved conflict, trauma, and other issues that might be contributing to fibromyalgia symptoms, is being studied as a treatment for the often debilitating illness.
During a symposium on medically complex illnesses at the annual convention of the American Psychological Association, Mark A. Lumley, Ph.D., provided some early observations from a multicenter randomized study comparing this approach with cognitive-behavioral therapy (CBT) and an education control group on 1-year outcomes. Because the wrong pathological processes might have been targeted, “relatively weak” techniques have been used to treat patients with fibromyalgia, said Dr. Lumley, professor of psychology, and head of the stress and health research laboratory at Wayne State University in Detroit.
Interpersonal and relational stress is typical among people with fibromyalgia and includes unresolved conflicts with parents, siblings, spouses, bosses, and others, he said, noting that being bullied on the job has been associated with a three- to fourfold increase in the risk of fibromyalgia. Moreover, 35%-50% of patients with fibromyalgia have evidence of posttraumatic stress disorder (PTSD), and 50%-70% have experienced “lifetime victimization and abuse in their lives,” he said.
Therefore, since PTSD, stress, or conflict “tend to be maintained by the avoidance of emotions related to the stress,” effective treatment should involve “some sort of exposure and processing of avoided emotionally laden experiences” dealing with memories, thoughts, or relationships, he explained.
Emotional exposure therapy (EET) techniques, based on the “experience-brain-emotion-symptom” model, entail reviewing physical symptoms and events over an individual’s lifetime and identifying key unresolved stressors or conflicts, “making the unspoken spoken,” Dr. Lumley said. This approach also involves engaging in expressive writing “often as unsent letters to a key conflict person,” and reenacting relational conflicts, “making the unexpressed expressed,” he explained.
A few years after finding that expressive writing was beneficial in patients with fibromyalgia, he and his associates conducted a pilot study of 10 patients with fibromyalgia and unresolved stress who received 10 sessions of individualized therapy (Psychotherapy 2008;45:165-72). After treatment that included techniques to help the patients “confront and process avoided emotions, memories, and relationships,” two patients showed substantial improvement with symptoms that were almost entirely resolved, and four experienced clinically meaningful improvements, Dr. Lumley said.
In the multicenter, randomized, controlled study of 230 patients with fibromyalgia, patients were treated in small groups with eight sessions of EET, CBT, or education control, and were followed up at 1 year. Almost all patients had a history of significant trauma or conflict, which included sexual abuse or assault in about half of the patients, substantial family of origin problems (in about two-thirds), conflicted or unhappy marriages (in about three-fourths) “and almost all had what I clinically view as emotional avoidance experiences,” he said.
Participation has been high, with 84% in the EET group, 77% in the CBT group, and 87% in the education control group making it to the last session – indicating that EET does not frighten all patients away, Dr. Lumley observed.
After 8 weeks of treatment, 22% of those randomized to EET were judged by the therapists providing the treatment to have experienced substantial changes, described as having their lives transformed and being “a very different person,” he reported. Another 29% were considered to have experienced “quite a bit of change,” and 17% were described to have experienced a moderate amount of change, with “a good start but a lot of work to do.” Another 19% experienced little change and 13% were resistant to or not open to treatment and did not change at all.
Patient reports reflected varied experiences, with comments that included, “It’s really hard, but I needed it.” Three patients said that the treatment “cured” their fibromyalgia and they that no longer needed to take medication and were sleeping well. These patients “did profound work in their relationships and resolved some of the conflicts in the sessions,” Dr. Lumley said.
But there were also some patients who said their pain increased after the sessions or that encouraging the expression of anger was dangerous, “so it can be a variable experience,” more variable than CBT, he noted.
Among patients who seek treatment for fibromyalgia, “there’s a lot of unresolved trauma and conflict” and most – but not all – of these patients need EET, Dr. Lumley said. “Many patients can and will do emotionally intense work,” while others might need a slower approach, possibly with expressive writing only or the use of emotional awareness techniques that do not involve expression, he added.
Others might benefit from learning “emotional downregulation strategies” with CBT first, he said, pointing out, “We need to figure out who is who.”
CBT, one of the few treatment options for fibromyalgia, has been the “psychological treatment of choice,” with techniques that include relaxation training, distraction and pleasant imagery, cognitive reappraisal of distressing thoughts, as well as scheduling and engaging in pleasant activities and healthy behaviors like exercise, he said.
The goal of CBT for fibromyalgia is to shift patients from a “medical treatment cure model” to a “chronic illness self-management” model. However, while CBT has resulted in significant changes over various control conditions, the effect sizes reported in studies have been too small to be noticed by patients, Dr. Lumley said. For example, based on the results of a 2013 Cochrane review, a patient with fibromyalgia could be told that with CBT, the “average patient’s pain improves about 0.5 points more on a 0-10 rating scale,” compared with typical treatments, he said (<cf number=\”1\”>ystematic reviews.\” </cf>Cochrane Database Syst. Rev. 2013 [doi:10.1002/14651858.CD009796.pub2]).
Fibromyalgia has been considered a psychosomatic condition or an unknown immune disorder in the past, but “a consensus is developing that it is sort of a central nervous system problem, [with] mostly brain, a little bit of spinal cord, and a little bit of the peripheral body involved,” he said. In addition to chronic widespread pain and tenderness, symptoms include fatigue and sleep and cognitive problems.
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