Effects of Cognitive-Behavioral Therapy (CBT) on Brain Connectivity Supporting Catastrophizing in Fibromyalgia

Abstract

Objective(s) Fibromyalgia (FM) is a chronic, common pain disorder characterized by hyperalgesia. A key mechanism by which Cognitive Behavioral Therapy (CBT) fosters improvement in pain outcomes is via reductions in hyperalgesia and pain-related catastrophizing, a dysfunctional set of cognitive-emotional processes. However, the neural underpinnings of these CBT effects are unclear. Our aim was to assess CBT’s effects on the brain circuitry underlying hyperalgesia in FM patients, and to explore the role of treatment-associated reduction in catastrophizing as a contributor to normalization of pain-relevant brain circuitry and clinical improvement. Methods Sixteen high-catastrophizing FM patients were enrolled in the study and randomized to 4 weeks of individual treatment with either CBT or a Fibromyalgia Education (control) condition. Resting state fMRI (rs-fMRI) scans evaluated functional connectivity between key pain-processing brain regions at baseline and post-treatment. Clinical outcomes were assessed at baseline, post-treatment and 6-month follow-up. Results Catastrophizing correlated with increased resting state functional connectivity between S1 and anterior insula. The CBT group showed larger reductions (compared to the Education group) in catastrophizing at post-treatment (p<0.05), and CBT produced significant reductions in both pain and catastrophizing at the 6-month follow-up (p<0.05). Patients in the CBT group also showed reduced resting state connectivity between S1 and anterior/medial insula at post-treatment; these reductions in resting state connectivity were associated with concurrent treatment-related reductions in catastrophizing. Discussion These results add to the growing support for the clinically important associations between S1-insula connectivity, clinical pain, and catastrophizing, and suggest that cognitive-behavioral therapy may, in part via reductions in catastrophizing, help to normalize pain-related brain responses in FM.

Mindfulness Meditation for Fibromyalgia: Mechanistic and Clinical Considerations

“…Fibromyalgia patients exhibit a number of pain-related alterations in neural processing that support the role of central sensitization and cognitive/emotional processes in facilitating pain [12, 19•, 20–22]. Specifically, during noxious pressure stimulation, fibromyalgia patients reported greater pain and heightened activation in pain-related brain regions including the insula, anterior/posterior cingulate cortex, cerebellum, and primary (SI) and secondary (SII) somatosensory cortices when compared to healthy, age- and gender-matched controls [19•].…”

“…Fibromyalgia patients exhibiting high rates of pain catastrophizing demonstrated increased connectivity between SI and the anterior insula, suggesting greater sensitivity during the evaluation of nociceptive processes in patients classified as high pain catastrophizers [12]. Interestingly, subsequent CBT participation reduced pain catastrophizing, clinical pain, and SI/anterior insula connectivity [12]. Reduced pain catastrophizing was also associated with lower clinical pain and SI/anterior insula connectivity [12].…”

“…Interestingly, subsequent CBT participation reduced pain catastrophizing, clinical pain, and SI/anterior insula connectivity [12]. Reduced pain catastrophizing was also associated with lower clinical pain and SI/anterior insula connectivity [12]. Psychological factors, such as pain catastrophizing, may be associated with fibromyalgia-related changes in neural network connectivity that subsequently heighten the experience of clinical pain.…”

“…CBT helps patients identify and reduce maladaptive cognitions/behaviors and includes psycho-educational didactics relevant to fibromyalgia, “journaling,” relaxation techniques, and real-world desensitization applications [9]. CBT may reduce fibromyalgia-related outcomes by attenuating psychological factors involved in facilitating pain, including anxiety [10], depression [10, 11], and pain catastrophizing [12]. Pain catastrophizing is a cognitive and emotional state where patients magnify the threat value of a pain stimulus, report helplessness in the context of pain, and are unable to inhibit intrusive pain-related thoughts [13].…”

Brain signature and functional impact of centralized pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study

“…This is supported by the observations of generalized hyperalgesia that these patients experience throughout the body [53], as well as enhanced brain responses to experimental pain [25; 37], altered brain connectivity patterns [22; 44], regional increases and decreases in brain gray matter [14; 33; 39; 51], and changes in brain neurotransmitter levels [9; 23; 29; 47] and their associated receptors [27; 55]. Some of these same brain outcomes dynamically change following successful pharmacologic [28; 49] as well as non-pharmacologic [30; 31; 42] therapy, and these changes concomitantly track with chronic pain improvement. If, as suggested, the brain is the primary locus for pathology in widespread pain patients, these individuals may be more likely to benefit from strategies that go beyond targeting an individual’s focal peripheral pain symptom [2; 15; 43].…”