Fibromyalgia & Cognitive Behavioral Therapy

  • March

    The Inquiry:

    Fibromyalgia (FM) or Fibromyalgia Syndrome is a complex, multi-faceted disease with many hypothesized causations and no true etiology. Many treatments have been explored with minimal success, noting that non-pharmaceutical treatments have been found to be more efficacious than pharmacological primary care treatments (Rendondo et al., 2004).

    I have a personal interest in Fibromyalgia having personal trained and treated people living with this condition. I am continuously inspired by her motivation and positive attitude to maintain a healthy and active life.

    The psychological link between perceived and experienced pain is fascinating and I proceeded to explore various successful treatments for Fibromyalgia with this in mind.

    Cognitive Behavioral Therapy (CBT) has been well known to aid in pain coping strategies, problem-solving, relaxation, and reducing catastophising thoughts through challenging maladaptive thoughts and attitudes (Thieme et al., 2006).

    My initial preliminary search with Pub Med for ‘Fibromyalgia and Cognitive Behavioral’ resulted in 146 articles and this prompted me to inquire into its treatment effects: Is Cognitive Behavioral Therapy an effective treatment for patients with Fibromyalgia Syndrome?


    What is Fibromyalgia?

    Fibromyalgia (FM) is a complex clinical syndrome with a wide array of symptoms experienced. Most commonly, FM is characterized by widespread chronic musculoskeletal pain, sleep difficulty, fatigue, and mood disturbances (anxiety and depression) lasting at least 3 months often leading to a poor quality of life (Kashikar-Zuck et al., 2012, Rendondo et al., 2004 and Thieme et al., 2006).

    Approximately  2-4% of the general population suffers from FM with the diagnosis made between 20-60 years of age and affects women 2 times more prevalently than men (Smith et al., 2011). Fibromyalgia Syndrome is most commonly diagnosed using the American College of Rheumatology criteria (Theime et al., 2006).

    Fibromyalgia is a central and possible peripheral pain disorder of an unknown etiology resulting in augmentation of peripheral stimuli, especially nociception with a generalized hyperalgesia (increased pain in response to normally painful stimuli) and/ or allodynia (pain in response to normal non-painful stimuli) (Rendondo et al., 2004 and Smith et al., 2004).

    There is speculation that FM is part of a larger continuum of central sensitivity syndromes (CSS) also known as functional somatic syndromes, medically unexplained symptoms, chronic multi-symptome illnesses and somatoform disorders (Smith et al., 2011).

    Hypothetical Mechanisms of Fibromyalgia

    Over the years, there has been an increasing amount of research into the mechanisms of Fibromyalgia Syndrome.

    A review article by Smith et al. (2011) summarizes many of the hypothetical pathophysiological dysfunction which are most likely a combination of the following:

    • Microglial activation leading to thalamic changes and abnormal neuronal hyper-excitability.
    • Diminished or inefficient descending inhibitory pathways due to reduced diffuse noxious inhibitory controls (DNIC) or conditioned pain modulation (CPM) leading to central sensitization and chronic pain.
    • Low amounts of cerebrospinal fluid (CSF) metabolites of biogenic amines (ie. Serotonin and norepinephrine) which help to regulate the descending inhibitory pathway.
    • Prolonged exposure to stress encourages persistent hyperalgesia by reduces dopamine output from the nucleus accumbens.
    • Significantly higher levels of Substance P in the CSF found in FM patients

    Conventional Treatments for Fibromyalgia

    Primary Care treatments by allopathic practitioners include a variety of pharmacological anti-depressants including (Garcia-Campayo et al., 2008 and Smith et al., 2011):

    • Amitriptyline (non-FDA approved),
    • Tramadol,
    • Milnaipran,
    • Moclobemide,
    • Fluoxetine,
    • Cyclobenzaprine (non-FDA approved),
    • Nortriptyline,
    • Duloxetine,
    • Pregabaline,
    • Zolpidem

    Controlled clinical trial literature suggests that although pharmacological agents provide some relief to Fibromyalgia patients, the effects are modest and are a huge cost to the health care system (Woolfolk et al., 2011 and Garcia-Campayo et al., 2008).

    Secondary care includes (Garcia-Campayo et al., 2008) :

    • Pirlindole,
    • Tropisetron,
    • DHEA,
    • Pramipexole,
    • Malic acid,
    • Rehabilitation,
    • Laser treatment,
    • Hyperbaric oxygen therapy,
    • Bright light treatment,
    • Aerobic exercise,
    • Exercise,
    • Stress-reduction treatment,
    • Chiropractic management,
    • Cognitive behavioural therapy,
    • Cognitive educational therapy,
    • Education training,
    • Behavioural insomnia therapy and
    • Music vibration

    Rendondo et al. (2004) found that non-pharmaceutical treatments are more efficacious than pharmacological ones with approaches such as exercise, education, and Cognitive Behavioral Therapy treatments being underutilized in usual clinical practice (Smith et al., 2011).

    Contrarily, a meta-analysis by Garcia-Campayo et al. (2008) observed that there are:

    “no differences in the overall outcome of FM regardless of the level of care (primary or secondary) in which the patient received”.

    I believe that even if non-pharmaceutical approaches have the same results as anti-depressant medications, the side effects and risk of aggravation are much lower and should still be considered as a primary care options, especially if given in combination with other approaches.

    Fibromyalgia and Cognitive Behavioral Therapy

    Alda et al. (2011) classifies Fibromyalgia Syndrome patients with catastrophism congnition, in which they are exclusively focused on pain and the belief that the worst possible outcome is going to occur, concentrating on negative vision (magnification), continuous rumination, and helplessness.

    There is a consistent relationship between catastrophizing and distress reactions to painful stimulations in patients with FM (Alda et al., 2011). Potential consequences associated with pain catastrophizing are heightened pain behaviors, increased pain intensity, greater analgesic consumption, reduced daily activity involvement, occupational disability and suicidal ideation (Alda et al., 2011).

    Cognitive Behavioral Therapy helps patients cope with pain and catastrophising responses by aiming to alter a person’s attitude towards pain and self-management (Thiere et al., 2006).

    Cognitive Behavioral Therapy (CBT) was created by Dr. Aaron Beck in the 1960’s to specifically helping patients living with depression. CBT combines aspects of both cognitive and behavioural interventions by focusing on taking catastrophic thoughts and reframing them into more positive beliefs (Smith et al., 2011).

    The Cognitive Behavioral manual by David et al. (2004) is designed for re-learning the physical, behavioural and emotional responses to a particular situation with A-B-C’s:

    A) Activating event or situation that a patient experiences is recognized;

    B) Beliefs or thoughts regarding the current situation;

    C) Consequences: how the patient feels or acts based on these beliefs.

    Once the activators, beliefs and consequences for those beliefs are recognized a more positive and rational way of thinking is implemented with the A-B-C-D-E-F protocol:

    A) Activating events;

    C) Consequences following the events;

    B) Beliefs (unhealthy or unhelpful)-

    i) All-or-nothing thinking,
    ii) Over-generalizing,
    iii) Mental filter,
    iv) Mind-reading,
    v) Catastrophizing (magnifying events out of proportion),
    vi) Minimizing the positive,
    vii) Personalization,
    viii) Jumping to conclusions,
    ix) Emotional reasoning,
    x) Demandingness (“should”, “must”, “ought” statements),
    xi) Labelling/ mislabelling,
    xii) Blaming

    D) Debating your negative beliefs

    E) Effective/ Helpful beliefs

    F) New more Functional emotions and behaviors


    Clinical Implications

    Researching Fibromyalgia and Cognitive Behavioral Therapy has been very valuable to me. I was already aware of my client’s ability to perceive their constant pain as a way of life and to not have them suffer from it. I see the benefits of continual treatment, homework assignments and combining other various treatments with CBT.

    This research has also opened my eyes to the easy ‘primary care’ treatment for FM with pharmaceuticals and how I can now challenge that they are no more effective and in certain circumstances less effective than Cognitive Behavioral Therapy.



    Fibromyalgia is an extremely complex and not well understood condition. As Naturopathic doctors, we have many tools to treat Fibromyalgia symptoms, aggregators, and causes with safe and effective modalities.

    The combination of Mind-Body energetic work can help to maximize treatment progress and minimize pain and depression. Cognitive Behavioral Therapy is only one tool that ND’s can use in combination to help the “incurable” patients with Fibromyalgia.



    Bernardy, K., Fuber, N., Kollner, V., Hauser, W. (2010). Efficacy of cognitive behavioral therapies in fibromyalgia syndrome—a systematic review and metanalysis of randomized controlled trials. J Rheumatol, 37:1991–2005.

    David, D., Kangas, M., Schnur, J.B., & Montgomery, G.H. (2004). CT depression manual; Managing depression using cognitive therapy.Babes-BolyaiUniversity (BBU),Romania.

    Dobson, K. S. (2008). Cognitive-behavioral therapy in the treatment of depression: Implications forCanada. Department of Psychology,UniversityofCalgary.

    Glombiewski JA, Sawyer AT, Gutermann J, Koenig K, Rief W, Hofmann SG. (2010). Psychological treatments for fibromyalgia: a metaanalysis. Pain, 151:280–95.

    Kashikar-Zuck S, Ting TV, Arnold LM, Bean J, Powers SW, Graham TB, Passo MH,Schikler KN, Hashkes PJ, Spalding S, Lynch-Jordan AM, Banez G, Richards MM,Lovell DJ. (2012). Cognitive behavioral therapy for the treatment of juvenile fibromyalgia: a multisite, single-blind, randomized, controlled clinical trial. Arthritis Rheum, 64(1):297-305.

    Rendondo, J. R., Justo, C. M., Moraleda, F. V, Velayos, Y. G., Puche, J. J. O., Zubero, J. R., Hernandez, T. G., Ortells, L. C., and Pareja, M. A. V. (2004). Long-term efficacy of therapy in patients with Fibromyalgia: A physical exercise-based program and a cognitive-behavioral approach. Arthritis Rheum, 51 (2): 184-192.

    Rossy, L. A., Buckelew, S. P., Dorr, N., Hagglund, K. J., Thayer, J. F., McIntosh, M. J., Hewett, J. E., Johnson, J. C. (1999). A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med, 21: 180-191.

    Smith, H. S., Bracken, D., Smith, J. M. (2011). Pharmacotherapy for fibromyalgia. Front Pharmacol, 2:17.

    Thieme, K., Flor, H., Turk, D. C. (2006). Psychological pain treatment in fibromyalgia syndrome: Efficacy of operant behavioural and cognitive behavioural treatments. Arthritis Res Ther, 8: R121.

    Vazquez-Rivera, S., Gonzalez-Blanch, C., Rodrigez-Moya, L., Moron, D., Gonzalez-Vives, S., Carrasco, J. L. (2009). Brief congnitive-behavioral therapy with firbromyalgia patients in Soutine care. Compr Psychiatry, 50 (6): 517-25.

    If you found this article valuable, please share it with anyone who may be dealing with Fibromyalgia or know of someone with Fibromyalgia. If you would like to receive any future articles pertaining to these topics, please send your contact information to

    Also, keep up-to-date on the latest research for Fibromyalgia and Chronic Fatigue Syndrome by read other related topics:

    Here are my FM/CFS book recommendations from fellow medical colleagues:

This website is NOT to be used as a diagnostic or treatment tool. Always consult with your Conventional Medical Doctor or Naturopathic Doctor for specific concerns. In cases of medical emergencies visit your nearest hospital or call 9-1-1.