Mieux vivre avec la fibromyalgie via un dispositif thérapeutique cognitivo-comportemental : étude du cas clinique « Mme L. »

Abstract

Les patients souffrant de fibromyalgie rapportent avoir eu un style de vie prémorbide comme « très dynamique, avec des journées très remplies, avec l’impossibilité de s’arrêter et le besoin d’aller jusqu’à l’épuisement en dépassant leurs limites ». Cette propension excessive à l’action (« ergomanie » ou « workaholism ») constitue à la fois un facteur de risque, facteur précipitant et un facteur d’entretien de la douleur fibromyalgique, entraînant fatigue et incapacité fonctionnelle. Ainsi, les patients fibromyalgiques peuvent finir par éviter toute activité physique de peur d’accroître leurs douleurs et la fatigue. L’objectif est de rendre compte d’un cas clinique qui présente une propension excessive à l’action traitée avec une thérapie comportementale et cognitive de groupe pour la gestion de la fibromyalgie au centre d’évaluation et traitement de la douleur de l’hôpital Saint-Antoine, Paris. Les résultats de cette étude corroborent ceux de la littérature sur l’efficacité de certaines techniques comportementales et cognitives telles que le « pacing ». Toutefois, ils méritent d’être approfondis pour proposer des stratégies efficaces pour apprendre aux patients à réguler leur comportement de propension excessive à l’action, augmenter leurs capacités physiques et leur bien-être et ainsi arriver à « mieux vivre avec la fibromyalgie ». Cognitive Behavioral Therapy (CBT) now has a place in the treatment of chronic pain (Williams et al., 2012 [28] ) and, in particular, fibromyalgia (Bernardy et al., 2010 [29] ). This debilitating pathology is characterized by chronic widespread pain associated with functional disability, fatigue, sleep disturbance, cognitive disorders and psychological distress. (Wolf et al., 2011 [1] ). Patients suffering from fibromyalgia often report having a hectic lifestyle before falling ill, a tendency to exhaustion and exceeding limits. This high action-proneness, (“ergomania” or “workaholism”) is both a risk factor (Aguerre et al., 2008 [7] ), a precipitating factor (“premorbid personality”) and a maintaining factor of fibromyalgic pain and its impact on life quality, through fatigue and functional disability. Patients with fibromyalgia eventually try to avoid all physical activity through fear of increasing their pain (Vlaeyen et al., 2000 [12] ). The aim of our work is to suggest behavioral and cognitive strategies such as “pacing” (McCracken et al., 2007 [14] ) to help patients with fibromyalgia regulate their physical activity gradually, step by step, taking into consideration their bodily sensations, their emotions, their limits, (Jammet and Laroche, 2012 [10] ) and also to improve their general well-being. Clinical case: Mrs L., 52 years old, lives with her retired husband. Their adult children have left home. Currently on sick leave, with the diagnosis of “fibromyalgia in a context of anxiety and depression”, she would like to return to work, but feels exhausted. She reported a difficult and isolated childhood, and mental and physical trauma. She describes alternating periods of hyperactivity and exhaustion prohibiting any activity, which matches “high action proneness” behavior. Assessment: This took place at three separate intervals: before and after the program, then nine months following the end of the CBT. The parameters assessed were: quality of life (questionnaire on the impact of fibromyalgia [QIF]), anxiety and depression (HAD), pain intensity (EVA), coping strategies (CSQ) and willingness to change (PSOCQ). Therapeutic proposal: inclusion in a cognitive-behavioral group program “Coping with fibromyalgia”, involving eight weekly two-hour sessions (Jammet and Laroche, 2012 [10] ), with four individual sessions and follow-up after the end of the therapy. Therapeutic procedure: The program implemented several strategies: information on and awareness of the psychological aspect of pain, cognitive restructuring, “pacing”, gradual return to physical and enjoyable activities, learning of coping strategies, stress management and emotion regulation techniques (Jacobson's progressive relaxation, work on “mindfulness” style body awareness). The assessments showed the acquisition of new coping strategies by our patient, notably with regard to activity and physical effort. She was able to plan her activities and take pauses (breathing, relaxation, distraction). Nine months after the program, there was a decrease in depressive signs (−80%), anxiety levels (46%) and dramatization (−60%). The intensity of pain over the last seven days had reduced by 40%, the score of the impact of fibromyalgia had decreased by 50%. Mrs L. has gone back to work fulltime. These results confirm the literature supporting the efficiency of certain behavioral and cognitive strategies in the treatment of fibromyalgia, notably “pacing” to reduce action proneness. The specific features, benefits and limits of this therapy will be discussed in the context of this case study which is a prototype of cognitive-behavioral treatment of a fibromyalgia group in the centre d’évaluation et traitement de la douleur “François-Boureau” at the hôpital Saint-Antoine in Paris.