Fig. 7.1
The pain matrix (Reprinted with permission from Bushnell and Apkarian [7]). ACC anterior cingulate cortex, Amyg amygdala, BG basal ganglia, HT hypothalamus, PAG periaqueductal gray matter, PB parabrachial nucleus, PCC posterior cingulate cortex, PF prefrontal cortex, PPC posterior parietal cortex, S1 primary somatosensory cortex, S2 secondary somatosensory cortex, SMA supplementary motor area
Given the significant degree of reciprocal overlap between the limbic/emotional and pain-processing areas of the cortex evident in Fig. 7.1, intuitively, any treatment which influences one is likely to affect the other. Pharmacological therapies are well known to influence neurotransmitter activity. But, what about the psychological/behavioral therapies? Over a decade ago, psychiatrist and Nobel Laureate Eric Kandel ([8], p. 460) proposed the following:
Insofar as psychotherapy or counseling is effective and produces long-term changes in behavior, it presumably does so through learning, by producing changes in gene expression that alters the strength of synaptic connections and structural changes that alter the anatomical pattern of interconnections between nerve cells of the brain. As the resolution of brain imaging increases, it should eventually permit quantitative evaluation of the outcome of psychotherapy.
This assertion was certainly prescient, given what we now know about the influence of psychological techniques on brain neuroplasticity. For example, using PET scan technology, Goldapple and colleagues [9] compared the effects of antidepressant treatment with paroxetine to that of cognitive behavioral therapy (CBT). CBT was found to have a modality-specific effect, producing unique blood flow changes in the frontal cortex, anterior cingulate cortex, and hippocampus. Thus, the effect of CBT was largely to normalize the metabolic activity of the prefrontal lobes. Other studies have also documented similar cortical changes facilitated by psychotherapeutic intervention for disorders including posttraumatic stress disorder, specific phobia, depression, and anxiety [10–14]. Such studies led to Dr. Kandel’s revised view, several years later, that “There is no longer any doubt that psychotherapy can result in detectable changes in the brain” [15].
Despite the appeal of the biopsychosocial model, medical pain specialists often unwittingly promote the “pain-as-functional-or-structural-abnormality” concept. The hope of surgeons and patients alike is that once the physical cause of the pain is identified and treated appropriately, the pain will be eliminated. The focused quest for a “pain generator” as well as the predominance of purely medical/physical modalities suggested as first-line options in published treatment guidelines from medical societies can lead some patients down an unsatisfying and incomplete path. This occurs especially if the somatic treatment recommended and attempted is ineffective, partially effective, or when a direct physiological cause cannot be immediately localized. Patients are often left to “just deal with” the residual, incurable symptoms on their own.
Psychological processes of learning and memory, mood and affect, social withdrawal and isolation, past traumatic events, pain beliefs, anticipation of pain exacerbation, and coping style can all play a role in an individual’s adjustment to chronic pain. All of these factors have the potential to influence the pain experience at several phases: at the onset of pain, during the seeking and receiving of healthcare and support, and in the development of chronic pain-related disability and work loss [16]. Recognizing the contribution of psychosocial factors to an individuals’ pain opens the door for the implementation of psychologically oriented cognitive and behavioral self-management strategies to address the remaining pain complaints and provide a more comprehensive, holistic approach to improving quality of life despite persistent pain.
Of note, acknowledging that psychological factors are involved with the pain experience does not mean that the pain is “in the patient’s head,” that is to imply, psychogenic or factitious in origin. As expressed by Andrew Miller in his novel Ingenious Pain, “All pain is real enough to those who have it; all stand equally in need of compassion” [17]. International studies show that nearly half of people with chronic pain still experience negative cognitive, emotional, and physical effects despite conventional medical therapies, as well as poor social and occupational functioning and overall lower quality of life [18, 19]. For example, the most potent drugs only decrease pain levels by 30–40 % in fewer than half of patients [20]. Surgical techniques such as artificial disk implantation or implantable drug delivery systems also provide modest pain reduction [20]. In addition to pain relief of limited clinical significance in inadequately screened patients, implantable devices also run the risk of adverse side effects [20, 21]. However, patients who participate in various forms of psychological interventions as a complement or adjunct to medical treatment have been found to significantly improve. Improvements in pain intensity, mood, coping, daily activity, and social functioning have all been reported [22, 23] without the risk of adverse physical consequences.
The inefficiency of even our best medical interventions may be due, in part, to the fact that many of the reasons for the inadequate responses to medical treatments are indeed psychological. Relevant psychological factors may include underreporting or exaggeration of pain intensity, inadequate communication skills between physician and patient, unrealistic or inappropriate expectations for outcomes, fears of addiction, fear of stigma, noncompliance to physical therapy exercise regimens, or other health behaviors. Addressing these psychological barriers can improve medical treatment outcomes and assist the patient in coping with any residual pain in the long term. Put simply, the goal of the psychological therapies is to help patients develop a satisfactory quality of life, whatever they define that to be within their own values and abilities, despite the persistent pain.
Clinical Examples and Usefulness in Clinical Practice
There are several evidence-based psychological therapies effectively implemented in clinical pain populations. These include but are not limited to (a) behavioral therapies modeled on operant and classical conditioning paradigms, such as exposure and desensitization to avoided activities; (b) cognitive behavioral therapy and acceptance-based therapies; (c) biofeedback and relaxation training; (d) group therapies; and (e) motivational enhancement therapy. Another technique that falls under the “psychological therapy” umbrella is hypnosis, which is covered elsewhere in this book. Insight-oriented and psychodynamic approaches, which are predicated on the belief that pain may be a manifestation of emotional distress and which emphasize the influence of early childhood experiences on the experience of pain in adulthood, will not be reviewed here in the interest of space and paucity of well-designed outcomes studies in pain populations. Some newer therapies such as narrative therapy [24] show promise in the management of chronic mental and medical illnesses, but as of yet there is very little literature on the efficacy of this modality among individuals with chronic physical pain. We will begin with some of the classic behavioral psychology conceptualizations and associated therapies.
Classical and Operant Conditioning Techniques
The most useful piece of learning for the uses of life is to unlearn what is untrue.
– Antisthenes
Most everyone with an undergraduate Psych 101 class under their belt is familiar with the concept of Pavlovian conditioning, also known as “classical” conditioning. In the landmark experiment, dogs were trained to salivate (conditioned response) at the sound of a ringing bell (conditioned stimulus) after numerous repeated pairings of the bell with meat powder (unconditioned stimulus). Thus, the dogs were eventually conditioned to anticipate food and salivate at the mere sound of the bell. Pavlov’s studies supported Aristotle’s observations of the “law of association by contiguity,” essentially paraphrased as “If a person experiences two environmental events (stimuli) at the same time or one right after the other (contiguously), those events will become associated in the person’s mind, such that the thought of one will, in the future, tend to elicit the thought of the other.”
This type of associative learning occurs in patients with chronic pain as well. Take, for example, a patient who has an unpleasant reaction like a spinal headache following a lumbar epidural block. This patient may develop a conditioned fear response to further epidurals, and the fear may even generalize to other contextual cues (e.g., needles) or other stimuli (e.g., other suggested interventional procedures). See Table 7.1 for an overview of classical conditioning terminology.
Table 7.1
Classical conditioning basic terminology and examples
Term | Definition | Example |
|---|---|---|
Unconditioned stimulus (US) | A stimulus that naturally triggers a response | A dental procedure that involves drilling |
Unconditioned response (UR) | A response that occurs naturally in response to the unconditioned stimulus | The increased heart rate and muscle tension that arises during the painful dental procedure |
Conditioned stimulus (CS) | A neutral stimulus, that when paired with an unconditioned stimulus, begins/triggers a conditioned response | The smell and sounds of the dentist’s office experienced during the procedure |
Conditioned response (CR) | A learned response to a previously neutral (conditioned) stimulus | Increased heart rate and muscle tension while sitting in the dentist’s waiting room at the next visit, exposed only to the smell and sounds of the office |
Therapeutic interventions based upon the premise of classical conditioning aim to replace the conditioned response through techniques that involve gradual exposure to the feared stimulus paired instead with a neutral or calming stimulus. In other words, individuals are taught to “unlearn” the anxiety symptoms. Techniques such as systematic desensitization are often and effectively used to treat panic disorder, specific phobias, and posttraumatic stress disorder [25]. Together with the provider, the patient who fears a needle would develop a hierarchy of increasingly anxiety-provoking scenarios (e.g., seeing a needle in the room, watching others receive a needle stick, feeling the prick on their own skin, and so on) and would be guided through the steps combined with deep breathing, other relaxation techniques, or pleasant thoughts. These steps are initially performed covertly using imagined scenarios until the patient’s subjective ratings of distress are tolerable; the patient then progresses to in vivo exposure to real-life situations.
Another promising desensitization therapy, called eye movement desensitization and reprocessing (EMDR), is also described by its developer [26] as both an information processing and an “integrative” form of psychotherapy. It was developed initially for work with specific traumas, involves multiple phases of therapy, and can lead to rapid resolution of negative emotions. The goal is to associate/pair calmer emotions with the traumatic memories and images; the individual recalls the event, but it is less upsetting. Techniques such as bilateral stimulation (alternating taps or auditory tones) or rapid lateral eye movements and substitution of neutral beliefs regarding the trauma are used. Most of the applied research and randomized controlled trials have been conducted with trauma samples like adult survivors of sexual abuse or assault, as well as natural disaster- and combat-related posttraumatic stress disorder [27–29]. However, there is some compelling early evidence that EMDR may be successful in the reduction and elimination of phantom limb pain and associated psychological consequences of amputation [30–33]. While intriguing, most of the studies using EMDR to treat pain have been case series with small sample sizes, and large-scale randomized controlled studies are, to date, lacking.
The consequences of an act affect the probability of it’s occurring again.
– B.F. Skinner
If you have ever disciplined a child, either through time-outs, spanking, taking away TV or video game time, or raising your voice, or if you’ve given in to a demand for a toy in a store checkout line to avoid a tantrum and stares of passersby, you have felt the influence of another type of conditioning known as operant conditioning. Operant conditioning involves the use of reinforcement-based techniques—giving praise, taking away aversive conditions—to either increase the likelihood of a future positive behavior (e.g., doing homework) through reward or to decrease the potential for a negative behavior (e.g., checkout line tantrums) through aversive consequences. There is evidence indicating that, compared to healthy controls, patients with chronic pain have increased sensitivity to operant conditioning factors such as reinforcement and punishment [34]. Indeed, the word “pain” has etymological roots with the words punishment and penalty [35]. Table 7.2 provides an overview of operant conditioning principles.
Table 7.2
Operant conditioning basic terminology and examples
Term | Definition | Example | Potential result |
|---|---|---|---|
Positive reinforcement | An increase in the probability of a behavior being repeated due to the addition of a positive consequence | After Mr. Smith displayed several verbal and nonverbal pain behaviors (B), his wife pays him increased attention (C) | Increased likelihood that Mr. Smith will display pain behaviors in order to solicit support and attention |
Negative reinforcement | Increase in the probability of a behavior being repeated due of the stopping or avoiding of a negative consequence | Mr. Smith takes a few extra oxycodone (B) which reduces his pain (C) | Increased likelihood that Mr. Smith will continue to self-adjust his medications in order to avoid anticipated pain |
Extinction | Decreases the probability of a behavior being repeated due to absence of expected consequence | Rather than responding to Mr. Smith’s pain behaviors, his wife instead ignores them (B) | Decreased likelihood that Mr. Smith will display pain behaviors around his wife |
Punishment | Decreases the probability of the behavior being repeated due to application of negative consequence | Mr. Smith’s physician, upon seeing another failed urine drug screen (B), declines to prescribe (C) Mr. Smith opioid medications any longer | Decreased likelihood that Mr. Smith will violate his pain treatment contract in the future |
One of the most common applications of operant conditioning in chronic pain patients is in the behavioral modification of overt pain behaviors. William Fordyce [36] was the first to recognize the effects of environmental factors in shaping the pain experience and to apply these principles to the treatment of chronic pain. Without standardized diagnostic procedures to quantify an individual’s unique experience of pain, clinicians are compelled to ask for self-reports, monitor overt signals (e.g., in-office postures, facial expressions, and affect), and make inferences about the patient’s pain from their verbal comments and observable behaviors.
Pain behaviors include (a) verbal responses such as moaning or gasping; (b) nonverbal responses including limping, grimacing, guarding painful limbs, and wincing; (c) generally reduced activity level including sitting and lying down; and (d) increased or prolonged use of therapies such as medications or a TENS unit to control pain [37]. These behaviors, either with conscious intent or more often unwittingly, elicit responses from observers. Family members may then acknowledge the patient’s pain through overly solicitous attentive responses, for example, taking over chores or rubbing the patient’s back. Physicians may respond with ordering unnecessary procedures or increasing medication doses. As a result of receiving these desirable consequences (i.e., positive reinforcement), the patient learns that their message has been received and the likelihood is increased that the patient will continue to exhibit the behaviors to obtain desired responses in the future. In addition, more adaptive well behaviors (e.g., working, doing laundry) may be overlooked and may extinguish with time.
Therapy based on operant conditioning principles has multiple goals: (a) making patients aware of their overt behaviors, (b) helping them realize more assertive ways of communicating about their pain, (c) educating spouses and families on how to respond with positive attention to desirable well behaviors or ignore/withdraw attention from unhealthy behaviors, and (d) reducing maladaptive or ineffective overt pain behaviors. Efficacy has been observed for this therapy across several chronic pain disorders, including low back pain [38] and fibromyalgia [39], although a more recent review indicates that it is not superior to cognitive or cognitive behavioral treatments for low back pain [40].
Interestingly, solicitous responses from spouses to nonverbal pain behaviors have been shown to be significant predictors of greater pain and physical disability in patients [41]. For example, women with chronic pain who have highly solicitous husbands show lower pain tolerance, greater pain-related interference, poorer performance on functional activity tasks, and greater use of opioid medications [42]. These results underscore the need to include the spouse/partner in clinical interviews and observe the interpersonal interactions. Intervention using couples therapy is warranted for patients with aggressive or overly solicitous spouses; couples can be educated on the operant conditioning model, and spouses can be trained to respond in more appropriate ways to improve the function of the patient.
Over time, you may notice that some patients start to restrict an expanding number of situations and activities (e.g., leave work, stop engaging in hobbies). Not only is an activity like work or exercise associated with an exacerbation of pain, the active person is, in effect, punished by the increase in pain intensity and discomfort. The individual learns to anticipate and fear the consequence and may choose to avoid the pain-provoking activity. Obviously, this process may reduce compliance to exercise and physical therapy and prevent engagement in adaptive household chores and social activities. The restricted movement may then become reinforcing because the aversive stimulus is avoided, increasing the likelihood of further activity avoidance.
A team of neuroscientists recently presented evidence that fear memories in adult rats are protected from erasure by compounds in the extracellular matrix of the amygdala [43]. In adult animals, fear conditioning induces a permanent memory that is resilient to erasure. In contrast, during early postnatal development, extinction of conditioned fear leads to memory erasure. This suggests that fear memories are actively protected in adults. Compounds called chondroitin sulfate proteoglycans (CSPGs) organize into perineuronal nets in the amygdala, and this coincides with the developmental switch in fear memory resilience. So, not only can avoidance of pain lead to worse functional outcomes, but the avoidance behavior can also strengthen the fear of pain, and our adult brains may take over to actively protect and preserve these fear memories.
Intuitively, avoidance may subsequently lead to muscle deconditioning, increased muscle tension, and amplification of pain. This concept has been promoted in the literature under a variety of constructs: anticipatory avoidance, fear-avoidance, and kinesiophobia, among others. The fear-avoidance model has been used to explain why a minority of acute low back pain sufferers develop a chronic pain problem [44]. It is also the force behind the use of quota-based exercise programs that proliferated in the early multidisciplinary behavioral pain programs [45], in which there is a gradual buildup of exposure to exercises and repetitions. However, more recent studies have called into question the hypothesized consequences of fear-avoidance for daily functioning [46], and sophisticated longitudinal design and statistical analysis suggest that fear-avoidance beliefs do not limit activity and cause pain/disability in a global manner [47].
Traditionally, operant conditioning therapies took place within inpatient pain rehabilitation environments to promote consistency, but there are no limitations to the settings where operant and classical conditioning can be effectively applied. Mental health providers may work with patients individually or with couples in outpatient or residential therapy settings. Physical therapists can apply reinforcement techniques and graded exposure during exercise sessions. Nurses and medical assistants often talk a patient through blood draws in a calming manner to reduce fear associations.
There are several ways for physicians to implement these behavioral techniques during office visits, on rounds, or even during quick consultations:
Avoid basing treatment plans solely on patient pain behaviors (e.g., “She’s not writhing on the floor, so she must not be a 9/10”) and conversely attempt to attend to and praise well behaviors. It has been shown that pain severity and other physical symptoms were significantly underestimated in patients with major depressive episode or panic disorder symptoms [48], who may appear excessive in their behavioral presentations. We do not want to reward or punish the patient with dramatic presentation nor undertreat the stoic patient.
Suggest time-contingent medication dosing rather than pain-contingent dosing and clearly explain the rationale and recommended time schedule (e.g., write q8h rather than t.i.d.).
Encourage activity pacing (remember the motto “Take a break before you need a break and then get back to it”) to break up the overactivity-pain-rest cycle and reassociate activity with positive outcomes.
Consider playing comforting music in post-procedure recovery rooms to associate a calming stimulus with a possibly uncomfortable and disorienting experience.
Classical and operant conditioning and their associated therapies are primarily subsumed under the umbrella of behavioral theories. You may be using them already more than you realize. While these therapies can be quite useful in addressing specific activity avoidance, overt pain behaviors, and overly solicitous spousal reactions, they fail to address an important factor in the development of maladaptive adjustment to chronic pain: cognition. This “second wave” of psychological therapies incorporates mental processes and responses and is known as cognitive behavioral therapy.
Cognitive Behavioral Therapy for Pain
If you don’t like something, change it; if you can’t change it, change the way you think about it.
– Mary Engelbreit
Imagine that you’re sitting in a chair in the corner of a dimly lit room, ruminating on life’s burdens, financial and social stressors, and uncomfortable physical symptoms. It’s not difficult to imagine that your mood would change, posture might slump, facial expression draw into a frown, and muscles become tense. Why, then, is it such a surprise that the opposite is true—that one’s mood could lift while in a sunny space, surrounded by supportive friends, distracted by enjoyed activities, or with kind words of self-encouragement? However, individuals with chronic pain often get stuck in a habitual cycle of negative thoughts about themselves, the world around them, and the future.
The cognitive part of cognitive behavioral therapy (CBT) for chronic pain management involves modifying such negative and maladaptive thoughts related to pain. Familiar negative statements include “This pain is killing me,” “I’m worthless because of the pain,” “No one understands my pain,” and “I can’t do anything because of this pain.”
CBT also focuses on increasing a person’s productive functioning in rewarding activities—the behavioral part, if you will. Cognitive behavioral treatment emphasizes active patient participation. Both didactic methods and Socratic dialogue are employed between therapist and patient. The four essential components of all CBT interventions are reviewed in further detail below and include (a) education, (b) skills acquisition, (c) cognitive and behavioral rehearsal, and (d) generalization and maintenance.
The best prescription is knowledge.
– C. Everett Koop
The education phase presents a credible rationale for the CBT intervention for chronic pain, encourages patients to believe they can actively manage their pain and mood, and integrates the CBT model with general health issues. Educational topics might cover pain mechanisms, activity pacing, sleep hygiene, proper use of pain medications, the pain-mood-behavior interaction, barriers to compliance, stress management, weight management, assertiveness and other communication skills, smoking cessation, and other health-related topics. In addition, before CBT techniques are implemented, the patient must learn and accept the cognitive behavioral model and be trained to identify thoughts, moods/emotions, environmental triggers, behavioral response patterns, and habitual belief systems.
During the next therapeutic phase called skills acquisition, maladaptive thoughts, feelings, and behaviors are slowly replaced with healthier and more effective alternatives. Behavioral skills include active relaxation training and controlled diaphragmatic breathing exercises to target reductions in autonomic arousal (discussed later in this chapter), attentional diversion from pain, training in assertiveness and problem-solving skills, pleasant activity scheduling, pacing activities to break the overactivity-pain-rest cycle, and other active health behavior strategies (e.g., implementing an exercise program, smoking cessation).
The negative thoughts of pain patients commonly fall into one or more of several categories. Some of the most common forms of distorted thinking or erroneous beliefs are seen in Table 7.3. One type of distorted negative thinking warrants special mention. You have seen a patient who is engaging in pain catastrophizing if you’ve heard the phrases, “My pain is killing me,” “I can’t cope with this,” and/or “My pain is always a 10 out of 10 and will never get better.” Defined both as a maladaptive appraisal or coping style and a stable dispositional trait, pain catastrophizing is most readily defined by its three components [49]: (a) magnification (exaggerated symptom perception), (b) rumination (inability to direct attention away from painful sensations), and (c) helplessness (feeling unable to cope with the pain given one’s present resources).
Table 7.3
Common types of pain-related cognitive distortions
Cognitive distortion | Examples |
|---|---|
Dichotomous/all-or-none thinking | “Unless my pain is cured, my life will never be good” |
“If I can’t dig in my garden, I won’t get outside at all” | |
Fortune telling/prediction | “I can’t go to church because I will end up experiencing more pain and be miserable the entire time” |
Mind reading | “Everyone at the store thought I was lazy because I was using the scooter” |
Imperative thinking/shoulds and musts | “I shouldn’t have to ask for help” |
“I should be able to mow my lawn in an hour like I used to” |
Pain catastrophizing is a particularly influential construct that has been shown to be a potent predictor of pain-related disability [50], quality of life [51], suicidal ideation [52], observable pain behavior and spousal response [53, 54], as well as postsurgical pain ratings and narcotic usage [55], often exceeding the contribution of depression itself to these outcomes. Pain catastrophizing has also been implicated as a predictor for poor response to minimally invasive procedures such as radiofrequency lesioning and injection treatments [56], as well as a predictor or persistent pain at two years following total knee arthroscopy [57]. With regard to mechanism of action, there is recent evidence that catastrophizing affects supraspinal endogenous pain-inhibitory and pain-facilitatory processes [58], is associated with dysfunctional cortisol responses [59], and may be linked to altered neuroimmunologic responses to pain [for an excellent critical review of the pain catastrophizing literature [60]].
Thus, during the cognitive skills acquisition phase, the patient is taught to monitor their thoughts, identify any irrational beliefs or thought distortions, and restructure the thought pattern toward more adaptive and realistic appraisals of the situation. For example, to “decatastrophize,” a patient would be guided to evaluate the realistic probability of her worst case imagined scenario and identify resources to cope with it. A therapist might ask, “What’s the worst thing that could happen with your pain?” “How sure are you that this will occur?” and “If so, then what? Could you cope with that?” With a teamwork approach and techniques such as modeling, role-playing exercises, and a careful questioning dialogue, a therapist will assist the patient with challenging their negative thoughts and encourage them to create alternatives. It is important to note that CBT is not about “putting on rose-colored glasses” and adopting a “Pollyanna personality,” which is just as distorted as one who habitually thinks through a negative filter. Rather, it is about adopting a realistic and neutral view of the pain and other situations.
Act the way you’d like to be and soon you’ll be the way you act.
– George W. Crane
The cognitive and behavioral rehearsal phase is a practice component to help the patient consolidate and master the newly learned skills in their natural environment. Homework assignments are often used with graded tasks to enhance the patient’s sense of self-efficacy or confidence in one’s abilities to use the new skills effectively and to reinforce their efforts.
The ultimate goal is generalization and maintenance, in which skills used for specific situations, such as coping with pain, generalize to everyday stressors across multiple environmental and social settings.
For example, we recall one particular patient who insisted that she felt angry and depressed following any type of exercise session. When asked what she was thinking about during her time on the treadmill, she responded that she aimed a rhythmic mantra toward the machine, “I hate this thing. I hate this thing. I hate this thing.” One may then see how this became a self-fulfilling prophecy in which the patient essentially talked herself into “hating” the exercise session and her mood shortly followed suit. Once she identified the negative thought, she was guided to create an alternative to use during her exercise sessions, for example, “This is good for me, I’m proud of myself for exercising.” She was asked to experiment with the alternative mental tapes during her session and track her thoughts, physical sensations, and mood before and after the exercise sessions in a diary format. When presented with the evidence that she felt better both physically and emotionally when she substituted the positive mantra, her efforts were reinforced and she began to look forward to the exercise sessions.
Evidence for Cognitive Behavioral Efficacy
The application of CBT for patients with chronic pain began nearly simultaneously with its advent in the early 1970s, although CBT and its close theoretical companion, rational emotive behavior therapy (REBT), were originally created with the intent to address more traditional psychological problems [61–63]. According to a review by Turk and colleagues [20], CBT—as a stand-alone treatment or when embedded within the framework of an interdisciplinary pain rehabilitation program—has shown strong empirical evidence of success in the treatment of chronic pain.
Several meta-analyses have indicated medium to large effect sizes for CBT-based interventions in both adult and child chronic pain populations [23, 64]. In addition to statistical significance by means of effect sizes, these studies also demonstrate clinical significance for pain reduction. For example, in one study a reduction of up to 68 % in headache frequency was observed from pre- to post-CBT treatment, as compared to 56 % for biofeedback and 20 % for a wait-list control condition [65].
CBT has been noted to produce significant changes in cognitive coping and appraisals, health-related quality of life, depression, social support, reported pain intensity, pain-related interference, return to work, and reductions in the behavioral expression of pain [22, 23, 65]. Improvements in physiological measures like heart rate, both at rest and in response to stress, have also been observed [65]. In general, CBT has strong empirical support as an effective treatment for chronic pain patients across a variety of conditions, including cancer pain [66], sickle-cell pain [67], low back pain [68–70], knee pain [71], rheumatoid arthritis [72, 73], vulvodynia [74], and temporomandibular joint pain [75], among others. Studies have compared treatment groups to waiting list controls, placebo medication conditions, and other treatment conditions such as physical therapy alone, education alone, and medical interventions alone. Improved outcomes have been shown to last at least 1 year or more, even among patients reporting long-term, preintervention disability [22, 23, 65, 76, 77]. There is also evidence from cross-lagged panel design studies that positive changes in cognitive process variables—including pain catastrophizing, helplessness, and pain anxiety—precede changes in pain-related outcomes in the context of multidisciplinary pain management programs [78].
CBT is also a cost-effective adjunct to medical interventions, associated with shorter hospital stays [79], and particularly when offered in group format. Brach and colleagues [80] performed an economic evaluation of 174 patients with rheumatoid arthritis randomly and blindly assigned to either a CBT group or client-centered supportive-experiential group (SET). Each group was performed as an adjunct module to a standard 2-week inpatient rehabilitation program. At 12-month follow-up, patients in the CBT group had fewer internist visits, fewer inpatient days, fewer day-care treatments, utilized fewer assistive devices, had lower medication costs, had fewer sick days, and required less caregiving from friends/relatives as compared to the SET group. All in all, the cost of adding either the CBT or SET group to the rehabilitation program was €47 per patient or about €282 per group [80].
Evidence for the efficacy of CBT has also come in the form of neuroimaging. Techniques such as magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and positron-emission tomography (PET) have documented neuroplastic changes produced by components of CBT. deLange and colleagues [81] examined volumetric changes after CBT in 22 patients with chronic fatigue syndrome (CFS) and 22 healthy controls. At baseline, CFS patients had significantly lower gray matter volume than controls. After CBT, these patients experienced an increase in gray matter volume, specifically in the lateral prefrontal cortex. Neuroplasticity secondary to cognitive behavioral treatment has been observed for a variety of disorders including specific phobia [13, 14] as well as depression, anxiety, posttraumatic stress disorder, and obsessive-compulsive disorder [10, 12, 82]. More specific to chronic pain, observed neuroplastic changes have been shown to especially involve neural regions implicated in the descending pain-inhibitory system: the anterior cingulate cortex (ACC), medial and lateral prefrontal cortex (particularly the dorsal lateral PFC), insula, periaqueductal gray, and ventromedial hypothalamus.
For example, enhanced perceived self-control over pain has been associated with increased activation of the prefrontal cortex in addition to attenuated activation in the ACC, insula, and secondary somatosensory centers, associated with reduced subjective pain perception [83]. Similarly, Salomons and colleagues [84] observed that individuals with greater perceived controllability of pain showed activation of the ventral lateral prefrontal cortex and reported less pain. Research indicates that endogenous opioid systems may be involved in cognitive pain coping—the opioid antagonist naloxone has been shown to block the beneficial analgesic effects of cognitive pain coping [85].
Pain is inevitable; suffering is optional
– Unknown
…You have already borne the pain. What you have not done is feel all you are beyond the pain.
– Saint Bartholomew [c. 1st century]
Acceptance-Based Therapy
As noted above, the traditional focus in CBT has been on teaching coping methods that emphasize control or change in the content of psychological experiences. The connotation of cognitive and behavioral coping skills training is that pain is an entity against which we must fight, control, or win. The constant struggle against pain is understandably exhausting and often frustrating. Acceptance and Commitment Therapy (ACT) is a recently evolved treatment model, one of the “third wave” or “third generation” behavioral and cognitive therapies that encompasses and extends CBT processes to instead engender a goal of “psychological flexibility” rather than control [86]. There are six important processes utilized in ACT, three of which have been studied in the context of chronic pain, including (1) acceptance [87, 88], (2) mindfulness-based methods that support awareness without judgment and “contact with the present moment” [89], and (3) values–related processes in relation to patient functioning [90] (for a full description of the six specific processes used in ACT, see [91]). In each of these studies, the ACT processes are significantly associated with improved emotional, physical, and social functioning [92].
In summary, CBT can target maladaptive thoughts and dysfunctional behaviors in a time-limited manner, either individually in outpatient therapy sessions or in a group setting. However, there are several brief interventions available to physicians in clinical practice:
Listen to the content and context of patient’s words. Suggest that they replace “shoulds and musts” with phrases that begin with “I’d like to.” Model for them to replace “I can’t…” with “I could if….”
If they are being particularly harsh on themselves or indecisive, ask them to identify how they might talk to a friend with a similar problem.
Ask them to rank their most cherished values (e.g., family, church, creative pursuits) and encourage them to focus their efforts on those goals despite pain.
Consider giving a brief screening instrument for depression, anxiety, or catastrophizing in your office.
Most importantly, be aware of the power of your own descriptors and prognostic statements.
During a recent intake interview, one of our patients commented, “My doctor told me he didn’t think the SI joint injection would work, but he’d do it anyway. He was right…it didn’t work.” That patient was unwittingly set up ahead of time for a treatment failure simply from the force of the physician’s comment. Similarly, phrases such as “You have the back of an 85-year-old,” or “Your back is crumbling to dust” can create powerful and persistent imagery, and said to a patient already prone to catastrophizing, might influence patient mood, behaviors, and future treatment outcomes.
Biofeedback and Relaxation Therapies
We have writing and teaching, science and power;
we have tamed the beasts and schooled the lightning… but we have still to tame ourselves.
– Wells, H.G.
Head and feet keep warm, the rest will take no harm.
– Thomas Fuller
Stare into a mirror and smile. Adjust your facial muscles until you create the most comfortable looking smile. Congratulations, you’ve just performed biofeedback. Biofeedback and the various forms of self-management relaxation therapies are generally classified as psychophysiological interventions. These therapies involve a systematic approach to increasing awareness of one’s cognitive and physiological responses to achieve a state of full body and mental relaxation and peace. Biofeedback is a procedure in which the therapist monitors an individual’s physiological responses through a feedback device (e.g., a computer, temperature gauge, heart rate monitor). Processes such as heart rate variability, electrodermal responses, skin temperature, brain waves through electroencephalography (EEG), and respiratory rate can all be tracked. The feedback is provided in real time as the patient uses various cognitive and behavioral techniques to learn how to control the bodily response. Forms of relaxation therapy include autogenic training, diaphragmatic breathing, guided imagery, and progressive muscle relaxation.
Biofeedback has been shown to be especially effective in the treatment of migraine, tension-type, and vascular headaches [93, 94]. A recent meta-analysis [95] revealed medium to large effect sizes, as well as reductions in frequency of headache attacks. Biofeedback promotes higher perceived self-efficacy and reductions in anxiety, depression, muscle tension, and analgesic use [64, 96]. Intention-to-treat and publication-bias analyses have also shown that these treatment effects remain stable for at least 14 months posttreatment, even when patients who withdrew were treated as nonresponders [64, 96]. Research in this area has demonstrated that biofeedback is more effective than headache monitoring, placebo, and other relaxation therapies, and its effects are enhanced when home training is combined with clinic-based therapies [97]. Biofeedback is effective for a variety of other conditions, including temporomandibular disorders, arthritis, fibromyalgia, and traumatic brain injury [98, 99].
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