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. 2026 Jun;23(3):255–265. doi: 10.36131/cnfioritieditore20260305

Psychodynamic Interventions for Fibromyalgia: A Systematic Review

Alessandro Torelli 1, Martina Mesce 1, Marco Cavicchioli 1, Sara Bottiroili 2,3, Lorys Castelli 4, Filippo Maria Nimbi 5, Martina Cangelosi 2, Agata Benfante 4, Annunziata Romeo 4, Alessia Renzi 1, Annalisa Tanzilli 1, Rachele Mariani 1, Chiara Pazzagli 1, Michela Di Trani 1, Piercarlo Sarzi-Puttini 6,7, Carmen M Galvez-Sánchez 8, Federica Galli 1
PMCID: PMC13316893  PMID: 42383142

Abstract

Objective

fibromyalgia (FM) is a chronic condition characterized by widespread pain, fatigue, sleep disturbances, and psychological distress, with a significant impact on quality of life. While cognitive-behavioral therapy has been extensively studied as a psychological intervention for FM, the effectiveness of psychodynamic interventions remains underexplored. This systematic review aims to synthesize the existing literature on psychodynamic interventions for FM, focusing on their impact on clinical and psychological outcomes.

Method

a systematic search was conducted across PsycINFO, Cochrane, PubMed, and Web of Science databases. A total of six studies meeting the inclusion criteria were identified, investigating different psychodynamic approaches, including Attachment-Based Compassion Therapy, Emotional Awareness and Expression Therapy, and shortterm psychodynamic psychotherapy.

Results

across these studies, psychodynamic interventions showed potential - but still preliminary - benefits, including reductions in pain severity, anxiety, depression, and psychological distress, alongside improvements in emotional functioning and quality of life. However, substantial heterogeneity across interventions, study designs, and outcome measures, combined with moderate-to-high risk of bias and the small number of available studies, limits the strength of the conclusions.

Conclusions

the current evidence does not allow definitive recommendations regarding psychodynamic interventions for FM. Further methodologically rigorous research is needed to clarify the specific efficacy, generalizability, and underlying mechanisms of these interventions.

Keywords: fibromyalgia, systematic review, treatments, psychodynamic

Introduction

Fibromyalgia (FM) is a chronic condition affecting the musculoskeletal system, characterized by widespread pain, fatigue, sleep disturbances, mood and cognitive disturbances (Macfarlane et al., 2017). This syndrome has a profound impact on patients’ physical and psychological well-being, frequently resulting in disability and a decline in quality of life (QoL) (Sarzi-Puttini et al., 2021). The precise etiology remains uncertain; however, it is postulated that abnormalities in pain processing, hormonal imbalances, sleep disruption, and autonomic nervous system dysfunction may be implicated. FM predominantly affects adults and is more prevalent among women, with an estimated prevalence of approximately 2% (Macfarlane et al., 2017). The diagnosis is made by excluding other conditions, as there are no specific tests to confirm the presence of FM.

Current treatment landscape and emerging needs

Despite advances in research and published guidelines, there is still debate regarding the optimal treatment strategies (Sarzi-Puttini et al., 2020). In the past, the management of chronic pain, including FM, depended mainly on pharmacological treatments. However, these approaches have often proven ineffective in the long term, underscoring the need for alternative strategies (Borchers & Gershwin, 2015). Current guidelines support a flexible interdisciplinary approach that integrates individualized treatment plans (Steglitz et al., 2012; Gatchel et al., 2014; Macfarlane et al., 2017). Within this context, psychological interventions have gained increasing recognition as essential components of comprehensive FM management.

The role of psychological factors in FM

The literature highlights that individuals with FM often experience severe psychological distress, which significantly impacts both the severity of the condition and their QoL (Galvez-Sánchez et al., 2019; Ghiggia et al., 2022; González et al., 2010; Mesce et al., 2025; Nimbi et al., 2024). Mood disorders are the most common comorbidities, with over half of FM patients receiving a lifetime diagnosis of depression (Kleykamp et al., 2021; Løge-Hagen et al., 2019). Recent studies have also demonstrated the prevalence of both current and lifetime psychiatric comorbidities associated with FM, including generalized anxiety disorder, bipolar disorder, panic disorder, post-traumatic stress disorder (PTSD), and specific phobias (Kleykamp et al., 2021). These robust associations between FM and emotional dysregulation reinforce the importance of psychological interventions as essential components of FM care. Moreover, emerging evidence suggests that unresolved emotional conflicts, attachment difficulties, and maladaptive affect regulation may contribute to the maintenance and exacerbation of FM symptoms, pointing toward the potential relevance of psychodynamically-oriented treatments.

relevance Psychodynamic and evidence approaches: gap theoretical

While Cognitive Behavioral Therapy (CBT) has been extensively studied in FM, demonstrating efficacy in pain management and psychological symptom reduction, evidence regarding psychodynamic interventions remains sparse, fragmented, and not yet systematically synthesized. This gap is clinically relevant, given that psychodynamic approaches aim to address emotional conflicts, affect regulation, interpersonal functioning, and internalized relational patterns – processes thought to influence chronic pain presentations. Psychodynamic treatments focus on the patient's internal psychological processes, including affective-cognitive patterns of self and others, which influence perceptions, thoughts, emotions, and actions. The goal is not only the remission of symptoms, but also the enhancement of psychological capacities through introspection and discovery in an authentic and safe therapeutic relationship (Shedler, 2010).

Luyten and Blatt (2012) identified seven distinctive characteristics of psychodynamic therapy that distinguish it from other psychological approaches: (1) focus on emotions and affective expression: patient's feelings are explored and articulated to address conflicting or unacknowledged ones; (2) exploration of attempts to avoid painful thoughts and feelings: conscious and unconscious avoidance behaviors are analyzed; (3) identification of recurring themes and patterns: the therapist helps patients to recognize recurring patterns in the patient's thoughts, feelings, and relationships; (4) discussion of past experiences: early relational experiences are explored to understand how they influence current behaviors (especially with attachment figures); (5) focus on interpersonal relationships: interpersonal difficulties are addressed to foster healthier relationships (drawing on object relations and attachment theory); (6) focus on the therapeutic relationship: the relationship between therapist and patient becomes an opportunity to explore past relational patterns, such as transference and countertransference; (7) exploration of fantasy life: patients are encouraged to talk freely to explore desires, fears, fantasies, and dreams.

This therapeutic approach is particularly relevant for conditions like FM, where chronic stress, emotional trauma, and unresolved conflicts can exacerbate physical symptoms (Yavne et al., 2018). By helping patients to recognize how emotions influence pain perception, psychodynamic therapy can improve coping strategies and emotional regulation. Furthermore, addressing attachment issues may foster healthier interpersonal dynamics, potentially improving overall emotional wellbeing and reducing pain perception (Lumley et al., 2021; Maroti et al., 2021).

Rationale and aims of the present review

Despite the theoretical relevance of psychodynamic approaches to FM, no review has yet systematically summarized the available evidence. This gap is problematic for several reasons: clinicians lack guidance on whether and when to consider psychodynamic interventions; researchers cannot identify priorities for future trials; and the field lacks a clear understanding of which specific approaches show promise. Understanding the current state of evidence is essential to inform clinical practice, identify knowledge gaps, and guide future research directions. Given the established role of emotional and interpersonal factors in FM, and the unique therapeutic targets of psychodynamic interventions, a comprehensive evaluation of existing studies is both timely and necessary. Therefore, the present study conducts a systematic review to synthesize and critically evaluate the existing empirical studies on psychodynamic interventions for FM. The aim is to clarify the current state of evidence, identify methodological limitations, and outline priorities for future research.

Method

Search strategy

Between December 2024 and January 2025, a systematic literature review was conducted utilizing the PsychoInfo, Cochrane, PubMed, and Web of Science databases. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure methodological rigor and transparency, and it was registered in the PROSPERO database (CRD420251244640). The search term “fibromyalgia” was used together with the Boolean operator (AND) to improve the accuracy of the results along with the search terms “psychodynamic”, “psychoanalysis”, “interpersonal therapy”, “brief psychotherapy”, “emotion-focused therapy”, “short term psychotherapy”, and “attachment therapy”. Seven search strings were formed and entered the databases (e.g., “fibromyalgia AND psychodynamic”).

Eligibility criteria

Eligibility criteria were defined prior to study selection. All published studies were considered, irrespective of publication date. As is common practice in systematic reviews, studies published in languages other than English were excluded (Stern & Kleijnen, 2020). Review articles, study protocols, commentaries, and case studies were also excluded. Eligibility criteria were structured according to the PICO framework:

  • Population (P): Studies including individuals diagnosed with FM, regardless of age, gender, or other demographic characteristics. Studies focusing on chronic pain populations without reporting data specific to FM patients were excluded.

  • Intervention (I): Studies evaluating psychodynamic interventions, such as brief psychodynamic psychotherapy, attachment-based compassion therapy, or other emotion-focused therapies of psychodynamic origin; interventions classified as “psychodynamic informed” were also eligible.

  • Comparison (C): Studies were eligible regardless of the presence of a comparison group. When present, comparators included other psychological interventions (e.g., CBT, mindfulness), treatment-as-usual, or inactive control conditions (e.g., waitlist).

  • Outcomes (O): Studies reporting clinical outcomes related to FM were included, such as pain reduction, improvements in QoL, emotional well-being, functional status, or psychological symptoms (e.g., anxiety, depression). Studies exclusively focusing on outcomes without a connection to clinical symptoms were excluded.

Additionally, experimental studies of any design were included, such as randomized controlled trials (RCTs), non-randomized controlled studies, pre-post studies, and observational studies that provided relevant data on the effectiveness of psychodynamic interventions. Studies examining non-psychodynamic treatments (e.g., pharmacological interventions, CBT, mindfulness) without a psychodynamic component, or studies lacking an intervention, were excluded.

Study selection process and data extraction

All records identified through the database search were screened by two independent reviewers (MM and AT). Titles and abstracts were first examined to exclude clearly irrelevant studies, after which the full texts of potentially eligible articles were assessed against the predefined criteria. Any disagreements were resolved through discussion or, when required, with the input of a third reviewer. The study selection process is documented in the PRISMA flow diagram (figure 1). Data extraction was carried out independently by the same two reviewers using a standardized template. Extracted information included study design, sample characteristics, diagnostic criteria for FM, intervention characteristics, comparison groups, outcome measures, and main findings (table 1). Any discrepancies were resolved by consensus. No automation tools were used, and no missing or unclear data requiring imputation were identified.

Figure 1.

Figure 1

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Flowchart

Table 1.

Characteristics of the included studies

Study Country Sample (mean age) Treatment Measures Psychological variables Main results
Lumley et al., 2008 United states 10 females
(56 years)		 Multi-stimulus, Multi-technique motional Exposure Therapy Impact of Event Scale-Revised (IES-R); Fibromyalgia Impact Questionnaire-Revised (FIQ); Arthritis Impact Measurement Scales–2 (AIMS-2); McGill Pain Questionnaire; Brief Symptom Inventory (BSI); Satisfaction with Life Scale (SWLS) Unresolved stress manifestations (avoidance, intrusions, hyperarousal); Impact of FMS symptoms; Limitations in daily activity performance; Pain adjectives (Pain Rating Index); Psychological symptoms (Global Severity Index); General life satisfaction The intervention proved effective for the variables examined, especially with regard to stress symptoms, emotional distress and life satisfaction
Scheidt et al., 2013 Germany 46 females
(23 ASTPP; 23 TAU)
(48.7 years)		 Adapted form of short-term psychodynamic psychotherapy (ASTPP) as compared to a primary care treatment (TAU) Fibromyalgia Impact Questionnaire (FIQ); Hospital Anxiety and Depression Scale (HADS); Symptom Checklist-27 (SCL-27); Pain Disability Index (PDI); Medical Outcomes Study 36-item Short Form (SF-36); Screening for Somatoform Disorders-7 (SOMS-7); Co-occurring therapies diary; Psychiatric diagnoses (ICD-10 research criteria) Impact of FMS symptoms; Depression and anxiety; Psychological distress; Painrelated disability; Health-related quality of life; Functional physical symptoms; Psychiatric diagnoses Both treatments reported improvement from baseline, with no significant differences in the effect of the two treatments.
Lumley et al., 2017 United States 230 participants (216 females, 14 males)
(49.13 years)		 Expression Therapy (EAET) compared to Fibromyalgia
Education (FE) and Cognitive Behavioral therapy
(CBT). All patients continued their usual care.		 Brief Pain Inventory (BPI); Modified 2011 ACR FM Survey Criteria;
Pittsburgh Sleep Quality Index (PSQI); Multiple Ability Self-Report Questionnaire (MASQ); Center for Epidemiological Studies-Depression Scale (CES-D); Generalized Anxiety Disorder-7 (GAD-7); PROMIS Fatigue short form; SF-12 Physical Component Score; Positive Affect Negative Affect Schedule; Satisfaction with Life Scale; Patient Global Impression of Change (PGIC)		 Pain during the past week; Cognitive dysfunction (e.g., memory, concentration, attention); Depressive symptoms; Anxiety symptoms; Fatigue; Positive and negative affect; Life satisfaction; Sleep problems; Health care use; Frequency / severity of other FM symptoms EAET was more effective than the FE group in terms of general symptoms, widespread pain, physical function, cognitive dysfunction, anxiety, depression, positive affect, and life satisfaction. In addition, a higher percentage of patients reported significant improvements. Compared to CBT, EAET showed no significant differences in efficacy on the variables of interest but led to a more pronounced reduction in fibromyalgia symptoms and widespread pain.
Montero-Marín et al., 2018 Spain 35 females
REL 52.21 years;
ABCT 50.83 years		 Attachment-Based Compassion Therapy (ABCT) combined with treatment as usual (TAU); Relaxation Group (REL) combined with treatment as usual (TAU) Fibromyalgia Impact Questionnaire (FIQ); Visual analog scale (VAS); Clinical Global Impression-Severity Scale (CGI-S); Pain Catastrophizing Scale (PCS); Hospital Anxiety and Depression Scale (HADS); EuroQol Visual Analog Scale (EQ-5D); Acceptance and Action Questionnaire (AAQ-II) Impact of FMS symptoms; Patient mental illness; Pain catastrophizing; Anxiety and depressive symptoms; Quality of life; Psychological flexibility ABCT proved more effective than the relaxation group about general health status (FIQ), even at the 3-month followup. It also showed efficacy on clinical severity, anxiety, depression, quality of life, and psychological flexibility. In contrast, it showed no improvement in pain catastrophizing.
Montero-Marín et al., 2020 Spain 35 females
(51.68 years)		 Attachment-Based Compassion Therapy (ABCT) combined with treatment as usual (TAU); Relaxation therapy combined with treatment as usual (TAU) Fibromyalgia Impact Questionnaire (FIQ); Hospital Anxiety and Depression Scale (HADS); Five Facets of Mindfulness Questionnaire (FFMQ); Self-Compassion Scale (SCS) Functional status, severity of anxiety symptoms, severity of depressive symptoms, trait mindfulness, selfkindness, common humanity, mindfulness (self-compassion). Acceptance and Commitment Therapy (ABCT) has proven effective in improving fibromyalgia (FM) symptoms and reducing anxiety and depression, compared to relaxation therapy, at posttest and follow-up. Furthermore, ABCT plus TAU produced significantly more significant increases in the mindfulness and self-compassion measures than relaxation therapy plus TAU.
Santos et al., 2022 Spain 11 females
(54.91 years)		 16-session version of attachment-based compassion therapy (ABCT-16) Hospital Anxiety and Depression Scale (HADS); Self-Compassion Scale-Short Form (SCS-SF); Experiences Questionnaire (EQ-D) Anxiety levels, depression levels, self-kindness, common humanity, mindfulness, decentering ABCT-16 showed a significant reduction in symptoms after 8 sessions, reliable improvement in anxiety, and improvement in depression. In addition, significant improvements in self-kindness, mindfulness, and decentralization were observed and maintained at follow-up. There was no improvement in common humanity.
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Risk of bias assessment

The methodological quality of the studies included was assessed using two validated instruments, depending on study design. Randomized controlled trials were evaluated with the Cochrane Risk of Bias 2.0 (RoB 2) tool (Eldridge et al., 2016) while non-randomized or uncontrolled studies were evaluated using the JBI for Case Series (Joanna Briggs Institute Critical Appraisal Checklist for Case Series; Munn et al., 2020). Two reviewers independently assessed risk of bias, and discrepancies were resolved through discussion.

Results

As mentioned above, the process of applying the inclusion and exclusion criteria is illustrated in figure 1. Duplicates and records identified as not relevant were removed. In the Cochrane database, only records classified under “primary studies” were considered; reviews were excluded at the initial screening stage to ensure that only original empirical studies were evaluated. Table 1 provides details characteristics of the included studies. Six studies met the eligibility criteria, evaluating a range of psychodynamic interventions: three studies used Attachment-Based Compassion Therapy (ABCT) (Montero-Marín et al., 2018, 2020; Santos et al., 2022), one used Multi-Stimulus, Multi-Technique Emotional Exposure Therapy (Lumley et al., 2008), one used Emotional Awareness and Expression Therapy (EAET) (Lumley et al., 2017), and one study used brief individual psychodynamic psychotherapy (ASTPP) (Scheidt et al., 2013). It should be noted that, as indicated by the authors, the two ABCT studies (Montero-Marín et al., 2018, 2020) are part of the same research protocol (TrialTrials.gov registration: NCT02454244).

Study Characteristics and Interventions

Attachment-based compassion therapy (ABCT)

ABCT consists of an eight weekly 2-hour group sessions tailored to patients with FM (García-Campayo et al., 2016; Montero-Marín et al. 2018, 2020). This intervention focuses on increasing self- and other-directed compassion through mindfulness practices, visualization exercises related to early attachment experiences, and techniques to foster acceptance, equanimity, and gratitude. Santos and colleagues (2022) adapted the original ABCT protocol (García-Campayo et al., 2016) into 16 weekly 1-hour sessions to accommodate cognitive difficulties commonly reported by FM patients, aiming to improve comprehension and reduce dropout rates. The revised version also included homework and guided meditation recordings.

Multi-stimulus, multi-technique emotional exposure therapy

The Multi-Stimulus, Multi-Technique Emotional Exposure Therapy developed by Lumley and colleagues (2008) involves an individual protocol of 10 sessions (one per week) of 60 minutes, targeting emotional avoidance. The intervention identifies avoided affective experiences and implements tailored exposure exercises intended to promote emotional processing, trauma resolution, and physical symptom improvement. Rather than prescribing uniform session content, the protocol is guided by overarching principles to enable personalization based on each patient’s avoided stimuli and emotional readiness.

Emotional awareness and expression therapy (EAET)

EAET was designed by Lumley and colleagues (2017) by integrating different therapies focusing on trauma and emotions: experiential, intensive psychodynamic, prolonged exposure, expressive writing, and therapeutic rescripting. Delivered in eight weekly 90-minute group sessions, the intervention helps patients understand how emotional conflicts contribute to pain, facilitating the awareness and expression of adaptive emotions and more authentic interpersonal communication. This approach posits that engaging with unresolved emotional experiences reduces central pain amplification.

Individual short-term psychodynamic psychotherapy (ASTPP)

The ASTPP intervention used in the study by Scheidt and colleagues (2013) consisted of 25 weekly sessions, lasting 50-60 minutes, of psychodynamic psychotherapy tailored explicitly to patients with pain symptoms (Scheidt, 2002). The therapeutic approach is based on a dysregulation model of psychosomatic illness and research on attachment styles and affect regulation in psychosomatic disorders. The intervention progresses through three phases: (1) establishing a supportive therapeutic relationship; (2) addressing interpersonal problems linked to negative relational experiences, conflicts, and somatic complaints, with particular emphasis on affect regulation and body awareness; and (3) consolidating changes and planning future management. The model integrates elements of interpersonal therapy and contemporary psychodynamic approaches.

Effects of interventions

Across the six included studies (Lumley et al., 2008, 2017; Montero-Marín et al., 2018, 2020; Santos et al., 2022; Scheidt et al., 2013) psychodynamic therapies showed positive effects on several relevant outcomes for patients with FM. Improvements were reported in pain (severity or disability), fatigue, sleep quality, emotional functioning, self-compassion, and mindfulness-related constructs.

FM impact

Overall health status/functioning, using the FM instrument of election the Fibromyalgia Impact Questionnaire (FIQ; Bennett, 2005), were assessed in four of the six studies; table 2 presents these findings in detail. Montero-Marín et al. (2018, 2020) reported significant improvements in the ABCT group compared to relaxation at post-treatment and 3-month followup, with large effect sizes (d = 1.33-1.38). These findings suggest that attachment-based approaches may therefore promote emotional regulation, leading to broader functional benefits than traditional medical interventions. In the study by Lumley et al. (2008), moderate to large effects on the overall status of FM were also found at follow-up (ES = 0.74), indicating that emotional exposure may lead to benefits in alleviating the overall burden of symptoms. Santos et al. (2022) and Lumley et al. (2017), on the other hand, did not report FIQ outcomes. Finally, Scheidt et al. (2013) observed improvements in FIQ in both ASTPP and TAU groups, with no significant differences between conditions. Clinically significant improvements (≥14% change) were observed in 48-75% of participants depending on the study and intervention. Overall, these findings suggest that integrating psychodynamic therapies into the management of FM may offer relief to patients by reducing the impact of FM symptoms.

Table 2.

Effects of psychodynamic treatments on FIQ scores across included studies

Study Treatment Baseline Mean (SD) Post-Treatment Mean (SD) Follow-up Mean (SD)
Lumley et al., 2008 MSMTEET 57.10 (15.30) - 45.70 3 months (21.00)
Montero-Marín et al., 2018, 2020 REL 61.12 (20.21) 61.22 (25.90) 67.82 3 months (17.77)
ABCT 68.37 (17.38) 43.51 (10.31) 49.13 3 months (15.07)
Scheid et al., 2013 ASTPP 50.10 (2.50) 46.70 (2.80) 42.70 (3.50)
TAU 54.20 (2.50) 50.90 (2.80) 6 months 45.30 (3.50) 6 months
Lumley et al., 2017 this variable was not observed
Santos et al., 2022 this variable was not observed
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Notes: FIQ: Fibromyalgia Impact Questionnaire; MSMTEET: Multi-Stimulus, Multi-Technique Emotional Exposure Therapy; REL: Relaxation therapy; ABCT: Attachment-Based Compassion Therapy; ASTPP: Individual short-term psychodynamic psychotherapy; TAU: Treatment as Usual.

Anxiety and depression

All studies except Lumley et al. (2008) measured anxiety and depression using scales such as the HADS (Hospital Anxiety and Depression Scale; Bjelland et al., 2002), the GAD-7 (Generalized Anxiety Disorder-7; Spitzer et al., 2006), or the CES-D (Center for Epidemiological Studies-Depression Scale; Radloff, 1977). Lumley et al. (2017) found that EAET significantly reduced depression and anxiety compared to FM Education and, to a lesser extent, CBT at follow-up. Montero-Marín et al. (2018, 2020) reported significant reductions in HADS-A and HADS-D scores for ABCT compared to relaxation at post-treatment and follow-up, with moderate to large effect sizes. Santos et al. (2022) observed significant improvements in anxiety and depression post-intervention and at 3.5-month follow-up. Scheidt et al. (2013) found no between-group differences, although both ASTPP and TAU groups improved across time. Taken together, these findings suggest the potential of psychodynamic treatments in alleviating anxiety and depression in patients with FM, supporting a holistic treatment strategy for this condition, which extends beyond physical complications. table 3 provides a comprehensive presentation of the results from the included studies.

Table 3.

Effects of psychodynamic treatments on anxiety and depression across included studies

Anxiety Depression
Study Treatment Baseline Mean (SD) Post-Treatment Mean (SD) Follow-up Mean (SD) Baseline Mean (SD) Post-Treatment Mean (SD) Follow-up Mean (SD)
Lumley et al., 2008 this variable was not observed this variable was not observed
EAET 9.14 (5.48) 7.18 (5.16) 7.24 6 months (4.91) (25.96 11.99) 19.62 (12.10) 19.25 6 months (11.39)
Lumley et al., 2017 CBT 7.57 (5.56) 6.23 (5.19) 5.82 6 months (5.03) (20.20 11.88) 16.35 (11.44) 17.33 6 months (11.90)
FM Edu 6.51 (5.21) 6.53 (5.14) 7.12 6 months (5.20) (18.30 11.69) 18.22 (11.21) 18.46 6 months (12.07)
Montero-Marín et al., 2018, 2020 REL 11.53 (6.06) 10.53 (5.24) 9.80 (4.84) 3 months 8.33 (6.67) 7.53 (4.81) 7.80 (5.99) 3 months
ABCT 13.95 (4.27) 7.65 (2.62) 7.60 3 months (2.82) 10.35 (3.28) 4.80 (2.84) 4.70 3 months (2.00)
Santos 2022 et al., 2022 ABCT-16 10.82 (3.92) 5.91 (2.12) 6.36 months (1.69) 3.5 7.73 (2.65) 3.18 (1.78) 3.73 3.5 months (2.87)
Scheid et al., 2013 ASTPP 8.30 (0.90) 8.80 (0.80) 7.60 12 months (0.80) 9.60 (0.90) 8.70 (0.90) 9.00 12 months (1.00)
TAU 8.40 (0.90) 8.80 (0.80) 8.10 12 months (0.80) 9.30 (0.90) 9.20 (0.90) 9.70 12 months (1.00)
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Notes: The tool used was HADS (Hospital Anxiety and Depression Scale), except for the Lumley et al., 2017 study, which used CES-D (Center for Epidemiological Studies-Depression Scale) and GAD-7 (Generalized Anxiety Disorder-7). EAET: Emotion Awareness and Expression Therapy; CBT: Cognitive-Behavioral Therapy; FM Edu: Fibromyalgia Education; REL: Relaxation therapy; ABCT: Attachment-Based Compassion Therapy; ASTPP: Individual short-term psychodynamic psychotherapy; TAU: Treatment as Usual.

Quality of life

QoL measures were reported in four studies (Lumley et al., 2017; Montero-Marín et al., 2018, 2020; Scheidt et al., 2013); table 4 presents these outcomes in detail. The effects of psychodynamic interventions on QoL, measured using scales such as the SWLS (Satisfaction with Life Scale; Diener et al., 1985), the VAS (Visual Analogue Scale EuroQol; Badia et al., 1999) or the SF-36 (Short Form Health Survey 36; McHorney et al., 1993), reflect a broader effectiveness that goes beyond physical and psychopathological symptoms, incorporating emotional and social dimensions relevant to patients with FM. EAET led to significant improvements in life satisfaction compared to FM Education, but not consistently relative to CBT (Lumley et al., 2017). ABCT showed improvements in health-related QoL relative to relaxation, sustained at follow-up (Montero-Marín et al., 2018, 2020). ASTPP, consistent with findings for other variables, led to improvements in health-related QoL over time similar to TAU, with no significant differences between groups (Scheidt et al., 2013). Lumley et al. (2008) and Santos et al. (2022) did not assess QoL outcomes.

Table 4.

Effects of psychodynamic treatments on quality of life across included studies

Study Treatment Measures Baseline (SD) Mean Post-Treatment (SD) Mean Follow-up Mean (SD)
Lumley et al., 2008 MSMTEET SWLS 14.59 (4.15) - 17.80 3 months (6.89)
EAET SWLS 15.72 (7.33) 18.06 (8.29) 18.89 6 months (8.43)
Lumley et al., 2017 CBT SWLS 18.28 (7.83) 19.23 (8.07) 19.64 6 months (7.81)
FM Edu SWLS 18.21 (7.39) 19.15 (7.64) 18.58 6 months (7.72)
Montero-Marín et al., 2018, 2020 REL VAS 53.07 (21.71) 56.87 (18.95) 61.67 3 months (15.66)
ABCT VAS 48.25 (13.01) 66.65 (10.77) 71.65 3 months (7.34)
Scheid et al., 2013 ASTPP TAU SF-36 SF-36 39.30 (2.20) 37.60 (2.20) 32.60 (2.00) 32.30 (2.00) 43.50 (2.30) 6 months 39.40 (2.30) 6 months
Santos et al., 2022 this variable was not observed
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Notes: MSMTEET: Multi-Stimulus, Multi-Technique Emotional Exposure Therapy; SWLS: Satisfaction with Life Scale; EAET: Emotion Awareness and Expression Therapy; CBT: Cognitive-Behavioral Therapy; FM Edu: Fibromyalgia Education; REL: Relaxation therapy; ABCT: Attachment-Based Compassion Therapy; VAS: Visual Analogue Scale (EuroQol); ASTPP: Individual short-term psychodynamic psychotherapy; TAU: Treatment As Usual; SF-36: Medical Outcomes Study 36-item Short Form.

Other outcomes

Across studies, additional improvements were reported in emotional distress, unresolved stress, psychological flexibility, self-compassion, and mindfulness-related constructs. Effect sizes ranged from small to large depending on the domain and study. For example, Lumley et al. (2008) reported moderate to large effects for emotional distress (ES = 0.79) and life satisfaction (ES = 0.77), but smaller effects for pain and disability. ABCT-related gains in mindfulness and self-compassion were associated with reductions in anxiety and depressive symptoms (Montero-Marín et al., 2020).

Overall, these results suggest that psychodynamic interventions may contribute to clinically meaningful improvements in several domains typically impaired in FM, particularly affect regulation, emotional distress, and general functioning. Given the heterogeneity of the interventions and study designs, findings should be interpreted cautiously, but they indicate promising potential for psychodynamic approaches in FM.

Quality of selected studies and risk of bias assessment

The methodological quality of the included studies was assessed using two tools recommended by Cochrane: RoB 2.0 for RCTs and the JBI Critical Appraisal Checklist for Case Series for non-randomized or uncontrolled studies.

For the three RCTs, the overall risk of bias ranged from "some concern" to "high risk." Two studies (Lumley et al., 2017; Montero-Marín et al., 2018) were assessed as having "some concern," primarily due to potential bias in outcome measurement, as participants were not blinded and outcomes were based on self-reported measures. The study by Scheidt et al. (2013) was assessed as being at "high risk," primarily due to missing outcome data, with additional concerns related to outcome measurement and selection.

For the non-randomized studies, methodological quality was variable. The pilot study by Lumley et al. (2008) exhibited moderate methodological issues, largely attributable to the lack of clarity in describing participant inclusion procedures and the lack of confirmation of consecutive case inclusion. The study by Santos et al. (2022) was assessed as being at high risk of bias due to unclear inclusion criteria, insufficient follow-up reporting, and incomplete description of key methodological domains. Overall, the included studies showed a moderate to high risk of bias; table 5 presents the risk of bias assessment.

Table 5.

Risk of bias assessment

Study Design Tool Overall risk of bias
Lumley et al., 2017 Two-site, three-arm, cluster-randomized controlled trial (RCT) RoB 2 Some concerns
Montero-Marín et al., 2018 Two-controlled arm randomized trial (RCT) RoB 2 Some concerns
Scheidt et al., 2013 Two-controlled arm randomized trial (RCT) RoB 2 High
Lumley et al., 2008 Single-arm pilot trial JBI Moderate
Santos et al., 2022 Single-arm pilot trial JBI High
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Notes: RoB 2: Cochrane Risk of Bias 2.0; JBI: Joanna Briggs Institute Critical Appraisal Checklist for Case Series

Discussion

This systematic review summarized the available empirical evidence on psychodynamic interventions for FM, identifying six studies that met the inclusion criteria. Although the literature remains limited, the findings suggest that some psychodynamic approaches may offer benefits for specific symptom domains in FM, although findings remain preliminary and heterogeneous.

Synthesis of the main findings

The six included studies evaluated diverse psychodynamic approaches: EAET (Lumley et al., 2017), ABCT (Montero-Marín et al., 2018, 2020; Santos et al., 2022), emotional exposure therapy (Lumley et al., 2008), and brief psychodynamic psychotherapy (Scheidt et al., 2013). Outcomes varied considerably both within and across studies.

Of the three randomized controlled trials, two demonstrated superiorities over control conditions on primary outcomes, though the pattern of effects varied considerably across outcome domains. Psychological outcomes showed more consistent improvements than pain-related measures: four of six studies reported significant reductions in anxiety or depression, whereas only three reported significant improvements in pain severity as a primary outcome. This suggests that psychodynamic approaches may be particularly effective for the emotional and functional dimensions of FM, with more variable effects on pain intensity itself.

More specifically, EAET (Lumley et al., 2017) significantly outperformed both FM education and CBT on depression and life satisfaction at 6-month follow-up. Montero-Marín et al. (2018) reported large effects for ABCT compared to relaxation on functional status (d = 1.33–1.38), with benefits maintained at 3-month followup. In contrast, Scheidt and colleagues (2013) found no significant differences between brief psychodynamic psychotherapy and treatment as usual on any outcome measure, despite both groups showing improvements over time. This negative result is noteworthy as it suggests that not all psychodynamic approaches are equally effective and that specific characteristics of the intervention, the duration of treatment (25 sessions in Scheidt et al. versus 8 sessions in other studies), or the patient population (patients with comorbid depression) may influence outcomes.

The two uncontrolled studies (Lumley et al., 2008; Santos et al., 2022) reported pre-post improvements with moderate to large within-group effect sizes (0.36 to 0.79), but the lack of control groups limits the interpretation of these results, as spontaneous improvements, regression to the mean, and placebo effects cannot be ruled out.

Across all studies, improvements were more consistent for psychological aspects (anxiety, depression, emotional distress), with less consistent effects on pain severity. Specifically, four of six studies reported significant improvements in anxiety or depression, while only three of six studies reported significant improvements in pain severity as the primary outcome. This suggests that psychodynamic interventions may be more effective for addressing the emotional and psychological dimensions of FM than for directly reducing pain intensity, although pain-related functional impairment (measured by the FIQ) showed improvements in several studies.

It is important to note that, even among studies reporting positive outcomes, considerable individual variability in treatment response has been observed. For example, the 2017 study reported that, although some patients experienced substantial pain reduction (22.5% achieved a pain reduction ≥50%), most did not reach this threshold (Lumley et al., 2017). This heterogeneity in treatment response highlights the need to identify patient characteristics that predict differential response to psychodynamic interventions.

literature Integration on FM with existing psychological

These findings are consistent with previous research on psychological interventions for FM, particularly CBT and mindfulness-based approaches, which have been widely studied and implemented. Numerous reviews have shown that mindfulness-based treatments and CBT have significant effects on FM (Bernardy et al., 2018; Haugmark et al., 2019; Kundakci et al., 2022; Sancassiani et al., 2017). Specifically, CBT has been associated with improvements in pain intensity, sleep quality, and quality of life, but has shown less consistent results on fatigue and depression (Heagney & Adams, 2024). Mindfulness-based stress reduction (MBSR) has also been shown to reduce anxiety and depression and improve quality of life (Veehof et al., 2016). Although previous reviews have also noted the predominance of CBT and multimodal treatments (Lami et al., 2013), psychodynamic interventions have demonstrated comparable or, in some cases, larger effects. For example, the effect sizes reported by Montero-Marín et al. (2018) for ABCT (d = 1.33–1.38) are substantially larger than those typically observed for CBT. Unlike CBT, which typically focuses on modifying pain-related cognitions and behaviors in the present, psychodynamic interventions explicitly address the links between past relational experiences, emotional conflict, and current somatic symptoms. For example, ABCT focuses on attachment patterns and self-compassion; EAET focuses on awareness and emotional expression related to trauma and conflict; and emotional exposure therapy addresses avoidance of emotionally charged experiences. These intervention goals may be particularly relevant for FM patients with prior trauma, interpersonal difficulties, or significant emotional dysregulation, factors that are prevalent in FM populations but typically not the primary focus of CBT protocols.

of psychodynamic Potential mechanisms treatments underlying the effects

The studies included in this review did not systematically investigate the mechanisms of therapeutic change. However, some studies have provided preliminary evidence on potential mediators. Montero-Marín et al. (2018) found that improvements in psychological flexibility partially mediated the effects of ABCT on FM functional status. Another study by the same research group (Montero-Marín et al., 2020) found that the common humanity aspect of self-compassion mediated improvements in anxiety and depression. These findings suggest that psychodynamic interventions may exert their effects, at least in part, through mechanisms that overlap with those proposed for acceptance-based therapies, such as increased psychological flexibility and self-compassion.

However, psychodynamic theory also suggests specific mechanisms of intervention, such as increased awareness and emotional regulation through accessing, experiencing, and integrating previously avoided emotions; modification of maladaptive interpersonal schemas derived from early attachment experiences; reduction of internal conflict between emotions, desires, and internalized standards; improvement of mentalization capacity and reflective functioning.

Future research should explicitly test these proposed mechanisms using appropriate statistical methods (e.g., mediation analyses, cross-lagged panel designs) and validated measures of the hypothesized mediators. Such research would help clarify whether psychodynamic interventions produce benefits through mechanisms distinct from, complementary to, or overlapping with those of other evidence-based treatments.

Clinical implications

Given the preliminary nature of the evidence, clinical recommendations should be made with due caution. The findings suggest that short-term psychodynamic interventions may be considered an option within a multimodal treatment approach for selected patients with FM, particularly when: (1) standard treatments (e.g., medications, CBT, exercise) have been insufficient; (2) emotional distress, interpersonal difficulties, or a history of trauma appear to significantly contribute to symptom maintenance; and (3) patients express interest in exploring the emotional and relational dimensions of their experience.

However, it should be emphasized that the evidence base is limited to six studies with significant methodological limitations, and no single psychodynamic approach has been tested in multiple independent studies. Furthermore, patient characteristics that predict treatment response have not been systematically identified.

Finally, it should be noted that the brevity of several interventions reviewed here (8–16 sessions) may increase their feasibility in settings where prolonged psychotherapy is not feasible. However, whether such brief interventions produce lasting benefits remains an empirical question that requires further investigation.

Limitations and future directions

Several limitations must be considered in this review. First, the available evidence is based on a limited number of studies (n = 6), characterized by substantial heterogeneity in intervention protocols, study designs, outcome measures, and follow-up duration, which limits comparability across studies. Second, the overall methodological quality was variable, with a moderate to high risk of bias identified in most studies, particularly related to outcome measurement, missing data, and incomplete reporting. These factors reduce the validity of the evidence.

Furthermore, some of the evidence derives from preliminary or non-independent investigations, such as the pilot study by Lumley et al. (2008), which preceded the subsequent randomized trial (Lumley et al., 2017), further underscoring the early stage of this research field. While the limited number of studies reflects the current state of the literature rather than shortcomings in the review process, these constraints prevent definitive conclusions about effectiveness.

Future research should prioritize randomized controlled trials with standardized measures and longer follow-up periods. Investigating potential moderators and mediators of treatment response, such as attachment patterns, emotional awareness, self-compassion, and psychological flexibility, will be essential to clarify which patients are most likely to benefit from psychodynamic interventions in FM.

Conclusions

This systematic review suggests that some psychodynamic interventions, including attachment-based and emotion-focused approaches, may be associated with improvements in several domains relevant to FM, particularly emotional distress, psychological functioning, and the overall impact of the condition. In studies demonstrating positive effects, benefits were observed across multiple clinically relevant outcomes, suggesting that addressing affect regulation, emotional processing, and relational schemas may represent a valuable therapeutic target in FM.

Although the current evidence base remains limited, the findings highlight the potential role of short-term psychodynamic therapies as complementary components within a multimodal treatment framework, alongside more established interventions such as CBT and mindfulness-based approaches. Importantly, the observed variability in treatment response underscores the need for personalized care that considers patients' emotional, relational, and psychological characteristics. Further methodologically rigorous research is needed to consolidate these findings and establish clinical indications. While psychodynamic interventions show promise and are theoretically sound, the current evidence base remains preliminary and does not yet support definitive clinical recommendations.

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