Emotional Expression Shows Benefits vs CBT for Chronic Pain

Nancy A. Melville

May 19, 2016

AUSTIN, Texas — A therapeutic intervention involving confronting and expressing emotional and traumatic experiences shows greater improvement in fibromyalgia pain compared with conventional cognitive-behavioral therapy (CBT), randomized trial results show.

It was also linked to significant pain reductions when offered as a one-time intervention in the primary care setting, researchers report.

"Current evidence-based psychological interventions for fibromyalgia, such as CBT, are relatively weak, we believe, because they do not help patients disclose, target, and resolve their conflicted emotional experiences," senior author Mark Lumley, PhD, professor of psychology at Wayne State University, Detroit, Michigan, told Medscape Medical News.

"We have demonstrated, however, that doing so leads to improved outcomes for patients with fibromyalgia, including a substantial minority of patients who no longer meet diagnostic criteria for fibromyalgia."

The findings, from the PAST-FM (Pain and Stress Treatment for Fibromyalgia) trial, were presented here at the American Pain Society (APS) 35th Annual Scientific Meeting.

The study included 230 patients with fibromyalgia who were randomly assigned to one of three types of therapy: Emotional Awareness and Expression Therapy (EAET); standard CBT, commonly used in management of fibromyalgia; or a control group of patients receiving education on the latest scientific evidence on fibromyalgia.

The EAET consisted specifically of disclosure of stressful experiences and experiential enactments to increase expression of emotions, as well as expressive writing and encouragement to engage differently in relationships.

"Patients engage in emotional relearning experiences, which usually involves directly confronting and working through, rather than avoiding, their conflicted thoughts, feelings, and relationships," Dr Lumley explained.

"This can be done by helping patients disclose their trauma or other struggles; become aware of their hidden emotions, such as anger, sadness, guilt, and love; and express them in a healthy manner both in therapy and in real life to key people."

The CBT approach used in the study meanwhile involved cognitive and behavioral exercises to manage fibromyalgia symptoms, such as relaxation, sleep hygiene, cognitive reappraisal, pleasant activities, memory techniques, and other skills.

Patients in each therapy group had eight group sessions of 90 minutes each, held weekly. They were 94% female and 77.8% white, with a mean age of 49.1 years.

In terms of the primary outcome of 50% pain reduction from baseline, patients in the EAET group had improvement that was as much as two to three times greater at post-treatment and sustained at a 6-month follow-up (17% and 21.9%) compared with CBT (6.1% and 8.5%) and the control group (7.2% and 11.7%).


Patients in the EAET group also had significant reductions in mean levels of pain severity, measured on the Brief Pain Inventory (BPI), compared with controls at post-treatment (P < .01); however, there were no significant differences at a 6-month follow-up.

Cognitive functioning, measured with the Multiple Abilities Self-report Questionnaire, was improved only in the EAET group at post-treatment (P < .001) and was greater in the EAET group than in the control group (P < .01), but not in the CBT group at the 6-month follow-up.

Significantly more patients in the EAET group (28.1%) no longer met diagnostic criteria for fibromyalgia after 6 months than in the CBT (5%) or control (13.3%) groups. Approximately one third of EAET patients (33%) reported being "very much" or "much" improved at post-treatment and follow-up, compared with 15.3% in the CBT group and only 4.1% of controls.


Dr Lumley noted that, although the study didn't provide data on the benefit of EAET continuing beyond the 8 weeks, some patients expressed a desire for a continuation.

"Quite a few patients found the meetings beneficial, but they had only started the process of meaningful change and wanted to continue. Thus, I believe that the EAET effects would have been stronger with longer therapy."

Dr Lumley added that the study's control condition may have affected the outcomes more than expected.

"This control condition probably was helpful to patients in that it presented the latest scientific information about a puzzling condition, and it is possible that this information actually helped patients overcome stigma, clarify their confusing condition, and help them communicate more successfully about their fibromyalgia with the family and providers," he said.

"The use of this active control condition certainly created a very conservative test of the effects of both CBT and EAET.  Both EAET and CBT likely would have had larger benefits if they had been compared to no treatment."

A second study from Wayne State researchers also presented at the meeting evaluated a similar approach of tapping into patients' stressful and emotional experiences with an interview designed to be used in the primary care setting for pain patients.

For that study, 75 patients (85% women; mean age, 39 years) were enrolled from a family medicine clinic with medically unexplained pain disorders, including localized chronic pain, fibromyalgia, and headaches.

The patients were randomly assigned 2:1 to a single 90-minute stress and emotion interview (n = 49) or a wait-list control group (n = 26).

As part of the stress and emotion interview, patients' stress experiences were linked to the development of pain and other health conditions during their lives. Patients were then engaged in experiential exercises to express emotions, such as sadness or anger, related to their stressors.

In the intent-to-treat analysis, patients receiving the targeted interview showed significantly greater reductions in pain severity (P = .006); pain interference (P = .002); global psychological symptoms (P = .01); and specifically reduced depression (P = .03) and interpersonal activity (P = .02) at a six-week follow-up, compared to controls.

The authors noted that clinical observations and patient reports revealed significant unresolved issues, including victimization or conflict, in most patients receiving the interviews.

"In psychology and primary care, these patients are typically treated with general stress management and anxiety and depression treatment, but we think what's underlying these symptoms is something deeper," first author Maisa Ziadni, MS, from Wayne State University, told Medscape Medical News.

"We wanted to target issues such as adult victimization, conflicts, or shame-based secrets these patients may have," she said. "We know that suppressing these emotions leads to pain and fatigue so the interview model engages the patients to express these symptoms."

The study's findings underscore potential benefits in the expression-based model.

"We had powerful results," Ziadni said. "We found we were able to reduce pain severity, reduce pain interference, reduce depression and interpersonal sensitivity."

The authors added that, in general, participants seemed to appreciate the interview.

"Even though patients struggled to express their emotions, they were typically thankful for this interview opportunity," they said.

In a meta-analysis http://www.jpain.org/article/S1526-5900%2815%2900957-8/abstract published this month on motivational interviewing and chronic pain, researchers analyzed seven studies with 962 patients and found benefits in short-term adherence to chronic pain treatment, but with possible publication bias and unclear benefits in patient function and short term benefits.

Coauthor Louise Sharpe, University of Sydney, New South Wales, Australia, said the EAET approach appears to offer a unique perspective, but more needs to be known.

"The results look very encouraging for this new approach, particularly given what appears to be a large sample and well analyzed data, but on the basis of one trial, I would remain somewhat cautious," she told Medscape Medical News.

Patients with chronic pain and fibromyalgia do generally have a higher rate of trauma than people without chronic pain, and a well-administered CBT approach would address the trauma, she explained.

"The fact that the CBT did not affect function seems to lead to questions about the adequacy of the CBT provided."

"It is also unusual to have pain as a primary outcome. Although patients often want the pain to reduce, a standard CBT approach would not focus on pain, but rather reducing disability and improving mood-related consequences of pain.

"[In addition], I am not sure how they dealt with participants who had not experienced a trauma, it would be unusual if all had unless it was an inclusion criteria."

"Overall, even for the trauma group, I would have thought that the fact that only 33% felt much or very much improved meant that the approaches offered may not have been optimal."

Regarding the inclusion of patients, Dr Lumley noted that the researchers did not select only patients with a trauma history.  

"The EAET approach does not target only trauma, but also a range of unspoken or unexpressed feelings, emotional and relational conflicts, and shame-based struggles (secrets)," he said.

"Certainly there were patients in the trial without trauma histories, but there were few or none who had optimal emotional and relational health.  Almost everyone had some issues that they needed to work on (e.g., assertiveness, loss, intimacy)."

The PAST-FM study received funding from National Institutes of Health grant AR057808. The authors and Dr Sharpe have disclosed no relevant financial relationships.

American Pain Society (APS) 35th Annual Scientific Meeting. Abstracts 488 and 509. Presented May 13, 2016.

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