title: Cognitive Behavioral Therapy increases pain-evoked activation of the prefrontal cortex in patients with fibromyalgia.
abstract: Interventions based on Cognitive Behavioral Therapy (CBT) are widely used to treat chronic pain, but the brain mechanisms responsible for these treatment effects are poorly understood. The aim of this study was to validate the relevance of the cortical control theory in response to an exposure-based form of CBT, Acceptance and Commitment Therapy, in patients with chronic pain. Forty-three female patients diagnosed with fibromyalgia syndrome were enrolled in a randomized, 12-week, waiting-list controlled clinical trial (CBT n=25; controls n=18). CBT was administered in groups of six patients during 12 weekly sessions. Functional magnetic resonance imaging (fMRI) during pressure-evoked pain was assessed before and after treatment or the 12-week period. Self-report questionnaires of depression and anxiety were administered pre- and posttreatment as well as 3 months following end of treatment. Patients treated with CBT reported larger improvement of fibromyalgia on the Patient Global Impression of Change measure, and improved depression and anxiety symptoms, compared to the waiting-list controls. However, there were no effects on clinical pain or pain sensitivity measures. An analysis of fMRI scans revealed that CBT led to increased activations in the ventrolateral prefrontal/lateral orbitofrontal cortex; regions associated with executive cognitive control. We suggest that CBT changes the brain's processing of pain through an altered cerebral loop between pain signals, emotions, and cognitions; leading to increased access to executive regions for reappraisal of pain. Our data thereby support our hypothesis about the activation of a cortical control mechanism in response to CBT treatment in chronic pain.
authors.affiliation: Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA, USA Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden Behavior Medicine Pain Treatment Services, Karolinska University Hospital, Stockholm, Sweden Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Karin B
authors.initials: KB
authors.lastname: Jensen
authors.forename: Eva
authors.initials: E
authors.lastname: Kosek
authors.forename: Rikard
authors.initials: R
authors.lastname: Wicksell
authors.forename: Mike
authors.initials: M
authors.lastname: Kemani
authors.forename: Gunnar
authors.initials: G
authors.lastname: Olsson
authors.forename: Julia V
authors.initials: JV
authors.lastname: Merle
authors.forename: Diana
authors.initials: D
authors.lastname: Kadetoff
authors.forename: Martin
authors.initials: M
authors.lastname: Ingvar
mesh_terms: D000328:Adult; D001007:Anxiety / Q000523:psychology; D059350:Chronic Pain / Q000209:etiology* / Q000503:physiopathology; D015928:Cognitive Behavioral Therapy; D003863:Depression / Q000523:psychology; D005260:Female; D005356:Fibromyalgia / Q000150:complications / Q000523:psychology / Q000628:therapy*; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000523:psychology; D017288:Pain Threshold / Q000502:physiology; D017397:Prefrontal Cortex / Q000503:physiopathology*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome