Transcript Fibromyalgia Psychological and behavioral therapies

Fibromyalgia
Customizing therapeutic
management
B. Van Houdenhove & P. Luyten
K.U.Leuven
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Outline
1. Introduction
2. Non-pharmacological therapies in FM:
efficacy, working mechanisms,
outcome predictors
3. Toward customizing FM treatment
4. Future treatment research
5. Conclusion
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1.
Introduction
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Fibromyalgia
consists of multiple symptoms
among which
chronic, generalized pain,
and pain hypersensitivity…
in the context of global stress system
disturbances
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–
generalized sensory hypersensitivity
physical and mental effort intolerance
neuropsychological deficits
mood disorder
sleep cycle dysregulation…
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“In addition to pain reduction, the factors that
may contribute to perceptions of improvement
among patients with fibromyalgia
may include…
…positive changes in fatigue, physical
functioning, mood, and impact on daily living”
Hudson JI et al. What makes patients with fibromyalgia feel better ?
J Rheumatol (in press)
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A further step…
Individualize
therapeutic management
of FM ?
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2.
Non-pharmacological
therapies in FM:
efficacy,
working mechanisms,
outcome predictors
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The efficacy of (mainly)
– Cognitive-behavioral therapy (CBT)
– Exercise therapy
has been investigated by systematic reviews /
meta-analyses of randomized controlled trials
(RCT’s)
van Koulil S, et al. Cognitive-behavioural therapies and exercise programmes for patients
with fibromyalgia: state of the art and future directions. Ann Rheum Dis 2007; 66: 571-81.
Häuser W, et al. Efficacy of multi-component treatment in fibromyalgia syndrome: A metaanalysis of randomized controlled clinical trials. Arthritis Rheum 2009; 61: 216-24.
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Results…
Psychological interventions
and exercise therapy are effective but…
relative small clinical improvements
Effects typically not maintained
over time
Efficacy not always translated
in effectiveness
Van Koulil S, et al.
Ann Rheum Dis 2007; 66: 571-81.
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– Efficacy = does the therapy work in ideal
circumstances (RCT) ?
– Effectiveness = does the therapy work
in real life (natural setting, often involving
complex cases) ?
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Results… (continued)
Often no correlation between
changes in pain
and symptoms
…and changes in psychological aspects
(e.g. pain behaviors, functionality,
self-efficacy, mood, coping…)
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Results… (continued)
Great individual
variation in treatment
response…
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Working mechanisms
CBT / exercise therapy may influence symptoms
and disability via…
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–
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redirecting reinforcement patterns
correcting dysfunctional thoughts, beliefs, attributions…
exposure to pain-related fear
education, physical reconditioning
…but these therapeutic ingredients
are not relevant
for every FM patient !!!
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Predictors of positive
therapeutic outcome
highly distressed patients
shorter history of complaints
good compliance
CFS: individual therapy
better than group program
???
Van Koulil S, et al. Ann Rheum Dis 2007; 66: 571-581.
Bazelmans et al. Psychother Psychosom 2005;74: 218-224.
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3.
Toward customizing
FM treatment
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Reasons for
unsatisfactory
therapeutic results
?
Therapeutic interventions in FM
do not always fit with
the patient’s individual characteristics,
needs, and preferences
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Patient-therapist variables
(‘non-specific’ therapeutic factors)
are often not sufficiently
taken into account
Dopkin P.L. Predictors of adherence to treatment in women with fibromyalgia.
Clin J Pain 2006; 22: 286-294.
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To be noticed…
FM patients reporting a history of childhood
adversity may have particular psychosocial
characteristics, e.g. personality disorders
Physicians / therapists should be aware of
such aspects that may have important
implications for the therapeutic encounter
Imbirowiecz & Egle. Eur J Pain 2003; 7: 113-119 .
Van Houdenhove B et al. J Musculoskelet Pain (in press).
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Therapeutic strategies may be
only effective
when rooted in a plausible
and acceptable therapeutic rationale
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So, what is ‘customized’
management ?
use of various (psychological
and biological / physiotherapeutic)
interventions
‘à la tête
du client’ …
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…giving attention to
the doctor – patient relationship
(and other non-specific factors)
….and based on
a plausible and acceptable
etio-pathogenetic
working hypothesis
(‘illness theory’) of FM
Biopsychosocial working hypothesis
about the etio-pathogenesis of FM / CFS
Predisposing factors
familial-genetic
early life stress
depression
personality / lifestyle
stress system dysregulation
Precipitating factors
physical stressors
psychosocial stressors
hyper-function hypo-function
?
Perpetuating factors
immune activation / central sensitization
physical
perceptual-cognitive
affective
personality / behavioral
social
iatrogenic
dysfunctional pain inhibition
illness perception
llness behaviour
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Psychotherapeutic and
physiotherapeutic approaches
could be customized
by targeting specific,
i.e. personally-relevant
perpetuating factors…
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Which perpetuating factors ?
Physical factors
Physical deconditioning
Sleep disturbance
Hyperventilation
Opportunistic infections
Personality factors
Perfectionism / dependency
Introversion
Problematic affect regulation
Alexithymia
Perceptual-cognitive factors
Prognostic uncertainty
Somatic hypervigilance /
preoccupation
Rigid somatic attribution
Catastrophising
Low self-efficacy
Behavioural factors
Lack of adaptation / acceptance
Periodical overactivity
Affective factors
Depression
Anxiety disorders
Kinesiophobia
Social factors
Lack of understanding
Membership of patient group
Secundary gain / operant
conditioning
Iatrogenic factors
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To be noticed…
Many FM patients still suffer from
ongoing life-stresses
Some have co-morbid depression
or a manifest post-traumatic stress disorder
(e.g. following a
car accident with whiplash trauma,
…or worse)
Van Houdenhove B, Egle UT, Luyten P: The role of life stress in fibromyalgia.
Curr Rheumatol Rep 2005; 7; 365-370.
In the long run…
The therapeutic aim
in FM should be broadened to:
helping patients realistically
adapt lifestyle and personal life goals
which may minimize self-generated
physical and mental stresses
…in order to refind ‘a new psychological
and neurobiological (?) equilibrium’
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Clinical implications:
What works for whom ?
myth of
‘one size fits all’
Who may be best helped by exercises?
Who may rather benefit from behavioral or cognitive interventions?
For whom would other approaches (family interventions, relaxation,
assertiveness training, sleep restoration, counseling…) most useful ?
Who may need a combination of strategies?
Who may need specialized psychiatric therapy ? etc.
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Organizational problems…
 Which clinician is best suited for coördinating the care
for FM patients ?
 How to individualize treatment within multidisciplinary
group settings ?
 Therapy on one-to-one basis ?
 What about the availability of psychotherapists /
physiotherapists who are interested in, and have experience
in these patients ?
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4.
Future therapeutic
research
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Is customized treatment more effective ?
Naturalistic studies on ‘complex patients’
Role of non-specific therapy factors
N=1 studies to elucidate processes of change
Identification of therapeutic subgroups
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Attempts to subgrouping…
Van Koulil S et al. Tailored cognitive-behavioral therapy for
fibromyalgia: Two case studies. Patient Educ Couns 2008; 71:
308-314.
Van Koulil S et al. Screening for pain-persistence and painavoidance patterns in fibromyalgia. Int J Behav Med 2008;15:
211-220.
Wilson HD et al. Toward the identification of symptom patterns in
people with fibromyalgia. Arthritis Rheum 2009; 61: 527-534.
Rutledge DN et al. Symptom clusters in fibromyalgia: potential utility
in patient assessment and treatment evaluation. Nurs Res 2009; 58:
359-367.
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5.
Conclusions
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Psychological ànd biological
interventions have a place
in FM treatment
but…
should be customized
and individualized…
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…targeting personally-relevant perpetuating
factors
in the context of a biopsychosocial working
hypothesis
…and taking non-specific therapeutic factors
into account
…in order to encourage the patient’s long-term
self-care, lifestyle changes, and life goal
re-orientation.
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