A Randomized Controlled Neuroimaging Trial of Cognitive Behavioral Therapy for Fibromyalgia Pain

Lee, J., Lazaridou, A., Paschali, M., Loggia, M. L., Berry, M. P., Ellingsen, D., Isenburg, K., Anzolin, A., Grahl, A., Wasan, A. D., Napadow, V., & Edwards, R. R. (2023). A randomized controlled neuroimaging trial of cognitive behavioral therapy for fibromyalgia pain. Arthritis & Rheumatology, 76(1), 130–140. https://doi.org/10.1002/art.42672

Summary by: Hagai Berenson

This study addresses the pervasive and debilitating nature of fibromyalgia (FM), a condition marked by widespread pain and significant negative emotional impact.

High levels of pain catastrophizing - a maladaptive cognitive-emotional response characterized by an exaggerated negative orientation toward actual or anticipated pain, Which also associates with increased pain severity, emotional distress, and functional impairment is often correlated to the condition of FM.

The authors discuss the role of cognitive behavioral therapy (CBT) as a mind-body intervention aimed at reducing pain catastrophizing and improving overall functioning in FM patients. While previous research has demonstrated the clinical benefits of CBT in managing chronic pain conditions, the specific neural mechanisms through which CBT exerts its effects on pain catastrophizing remain unclear.

To investigate these mechanisms, the study was designed as a randomized controlled trial with a neuroimaging component.

The study enrolled 114 adult women diagnosed with fibromyalgia, aged between 18 and 75 years and were randomized into two groups:

CBT Group: 64 participants received an 8-week individual CBT program. This intervention focused on identifying and modifying maladaptive thoughts and behaviors related to pain.

Education Control (EDU) Group: 34 participants received an 8-week fibromyalgia education program, matched in duration and structure to the CBT intervention. The control group received education about fibromyalgia and chronic pain without the active cognitive restructuring components inherent in CBT.

98 of the 114 participants in this study also completed a neuroimaging assessment on a baseline level and post intervention.

These Participants engaged in a task designed to elicit pain catastrophizing thoughts while undergoing fMRI scanning. This involved reflecting on personalized pain-related statements to activate relevant brain regions associated with catastrophizing.

The primary objective was to assess the impact of an eight-week individual CBT program on pain catastrophizing and to explore the associated changes in brain functional connectivity, particularly focusing on the default mode network (DMN) and its interaction with somatomotor and salience network regions.

The assessment was made in two parts:

Questioners filled by all participants at baseline and post-CBT intervention:

Pain Catastrophizing Scale (PCS): Assessed the degree of catastrophic thinking related to pain.

Brief Pain Inventory (BPI): Evaluated pain severity and the extent to which pain interfered with daily activities.

Fibromyalgia Impact Questionnaire Revised (FIQR): Measured the overall impact of fibromyalgia on the individual's functioning and well-being.

For the neuroimaging assessment, the focus was on examining functional connectivity patterns, particularly involving the ventral posterior cingulate cortex (vPCC), a key node in the default mode network (DMN). The analysis aimed to identify changes in connectivity between the vPCC and other brain regions implicated in pain processing and emotional regulation, such as the somatomotor and salience networks.

The results showed that participants in the CBT group experienced significantly greater reductions in pain catastrophizing, pain interference, and overall fibromyalgia symptom impact compared to the education control group. Mediation analysis further revealed that reductions in pain catastrophizing partially explained the improvements in functional outcomes, suggesting that changes in maladaptive thinking patterns were a key mechanism through which CBT exerted its effects. Neuroimaging findings supported these behavioral outcomes, showing decreased functional connectivity after CBT between the ventral posterior cingulate cortex (vPCC)—a central hub of the default mode network—and regions in the somatomotor and salience networks. These neural changes were not observed in the control group, indicating that CBT may help recalibrate brain activity associated with excessive self-referential and pain-focused processing.