General Hospital Psychiatry xxx (2013) xxx–xxx

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General Hospital Psychiatry

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What is the evidence for specific factors in the psychotherapeutic treatment offibromyalgia? Comment on “Is brief psychodynamic psychotherapy in primaryfibromyalgia syndrome with concurrent depression an effective treatment? Arandomized controlled trial”

We read with great interest the paper by Scheidt and colleaguescomparing the efficacy of brief psychodynamic therapy (PDT) andenhanced treatment as usual (TAU) in patients with fibromyalgiasyndrome and comorbid depression and anxiety [1]. This study is awelcome addition to the growing evidence base demonstrating theefficacy of PDT in fibromyalgia and related conditions [2].

Yet, the absence of any notable differences in the efficacy of bothtreatments, with both treatments resulting in clinically significantchange in approximately 40%–50% of patients, deserves furtherdiscussion given the marked difference in intensity and frequency ofthe two treatments. Moreover, ameta-analysis has shown brief PDT tobe effective versus control treatments for a broad range of somaticsymptom disorders [2]. Eight studies in this review included patientswith chronic pain including studies of conditions that would now becalledfibromyalgia. Eight of these studies also includedmedical care asusual controls not dissimilar to the one in Scheidt et al. This leads us towonderwhy PDT in this study relatively underperformed compared tomedical care as usual, especially given the fact this TAU was only fourshort sessions. The authors argue that concurrent treatments such asaerobic exercise andmedicationmay have confounded the results, butneither treatment had effects on depression or anxiety! Furthermore,the authors speculate that the relatively modest effects of bothtreatments may have to do with comorbidity. Yet, brief PDT has beenshown to be effective for patients with depression [3,4] andpersonality disorders [5]. Moreover, in Abbass et al. [2], ratings on allof depression, anxiety and somatic symptoms showed benefits infavor of PDT over controls. None of the outcome measures weresignificantly superior to TAU in the Scheidt et al. study.

In our opinion, three alternative explanations need to beconsidered. First, the trial is clearly underpowered to detect smallbut perhaps meaningful differences in effect sizes. Second, wewonder about the roles of very limited training exposure (only 4 h)and relatively limited therapist experience in the PDT group. As theauthors note, the rheumatologist providing TAU was highlyexperienced, which may also point to therapist effects as well asthe potential role of common factors in explaining treatmentoutcome in these patients. Indeed, a recent review showed thattreatments that are based on very different assumptions about thenature of fibromyalgia and that use very different specifictechniques have very similar effects [6]. This suggests a role forcommon factors such as a positive therapeutic alliance andproviding patients with an acceptable illness theory and treatmentapproach, rather than specific techniques [7].

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Please cite this article as: Luyten P, Abbass A, What is the evidence for spGen HospPsychiatry (2013), http://dx.doi.org/10.1016/j.genhosppsych.2

Second, in terms of the treatment approach, the interventiondescribed sounds more of an insight-based versus an emotionallyfocused experiential model of brief PDT. Emotionally focused treat-ments, oftenmuchmore brief than the PDT intervention in Scheidt et al.,have been found to have large and significant effects that increased infollow-up with pain disorders [2]. The reason for this may be that thedifficulties many of these patients experience with recognizing andprocessing emotions may best be addressed through both mobilizingand examining emotions that otherwise produce or exacerbate somaticcomplaints through striated muscle tension, smooth muscle effects andother effects. Hence, an insight-oriented focus on attachment andtrauma without sufficient attention to emotional processing might beless effective and potentially even have iatrogenic effects. Alternatively,such a focusmight only be effectivewithin a longer treatment approach.Many authors have argued that treatment approaches for these patientsshould give more attention to feelings of invalidation of these patientswithin amore active and structured treatment approach that focuses onemotional processing and their links to attachment and interpersonalissues in the here and now [7–9], rather than on fostering insight inattachment issues in the past. This latter approach may overstimulatethe patient, leading to a decoupling of mentalizing capacities, feelings ofestrangement and difficult-to-handle patient–therapist issues [9,10].This may be particularly problematic in patients with high levels ofattachment trauma as in the Scheidt et al. study.While it is very difficultto judge these issues in the absence of process-outcome and adherencedata, these speculations call formore detailed process-outcome researchwith attention to adherence issues and potential iatrogenic effects oftreatments, and we would appreciate the perspective of the authors onthese issues.

Patrick Luyten, PhDFaculty of Psychology and Educational Sciences

University of Leuven, BelgiumResearch Department of Clinical, Educational and Health Psychology

University College London, United KingdomE-mail address: patrick.luyten@ppw.kuleuven.be

Allan Abbass, MDCentre for Emotions and Health, Dalhousie University

Halifax, NS, Canada

Available online xxxx

http://dx.doi.org/10.1016/j.genhosppsych.2013.07.007

ecific factors in the psychotherapeutic treatment of fibromyalgia?....013.07.007

2 Correspondence / General Hospital Psychiatry xxx (2013) xxx–xxx

References

[1] Scheidt CE, Waller E, Endorf K, et al. Is brief psychodynamic psychotherapy inprimary fibromyalgia syndrome with concurrent depression an effective treat-ment? A randomized controlled trial. Gen Hosp Psychiatry 2013;35:160–7.

[2] Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy forsomatic disorders. Psychother Psychosom 2009;78:265–74.

[3] Driessen E, Cuijpers P, de Maat SCM, Abbass AA, de Jonghe F, Dekker JJM. Theefficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis. Clin Psychol Rev 2010;30:25–36.

[4] Abbass A, Driessen E. The efficacy of short-term psychodynamic psychotherapy fordepression: a summary of recent findings. Acta Psychiatr Scand 2010;121:398.

[5] Town JM, Abbass A, Hardy G. Short-term psychodynamic psychotherapy forpersonality disorders: a critical review of randomized controlled trials. J PersonalDisord 2011;25:723–40.

Please cite this article as: Luyten P, Abbass A, What is the evidence for spGen HospPsychiatry (2013), http://dx.doi.org/10.1016/j.genhosppsych.2

[6] Luyten P, Van Houdenhove B. Common and specific factors in the psychothera-peutic treatment of patients suffering from chronic fatigue and pain disorders. JPsychother Integration 2013;23:14–27.

[7] Lumley MA. Beyond cognitive–behavioral therapy for fibromyalgia: addressingstress by emotional exposure, processing, and resolution. Arthritis Res Ther2011;13:136.

[8] Hambrook D, Oldershaw A, Rimes K, et al. Emotional expression, self-silencing,and distress tolerance in anorexia nervosa and chronic fatigue syndrome. Br J ClinPsychol 2011;50:310–25.

[9] Luyten P, Van Houdenhove B, Lemma A, Target M, Fonagy P. Vulnerability forfunctional somatic disorders: a contemporary psychodynamic approach. JPsychother Integration 2013;23:14–27.

[10] Luyten P, Van Houdenhove B, Lemma A, Target M, Fonagy P. An attachment andmentalization-based approach to functional somatic disorders. PsychoanalPsychother 2012;26:121–40.

ecific factors in the psychotherapeutic treatment of fibromyalgia?....013.07.007