Psychological therapies for the management of chronic pain – very long and excellent Free full text PubMed article
Pain is a complex stressor that presents a significant challenge to most aspects of functioning. As medical intervention frequently cannot resolve pain completely, there is a need for management approaches to chronic pain, including psychological intervention. Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning rather than focusing on resolution of pain itself
These therapies fall into four categories:
- operant-behavioral therapy,
- cognitive-behavioral therapy, (CBT)
- mindfulness-based stress reduction therapy, and (MBSR)
- acceptance and commitment therapy (ACT)
The current article explores the theoretical distinctiveness, therapeutic targets, and effectiveness of these approaches as well as mechanisms and individual differences that factor into treatment response and pain-related dysfunction and distress.
Introduction to the nonpharmacological treatment of pain
Pain is an essential biological function that signals disturbance or damage in the body, prevents further harm through overuse of the afflicted area, and promotes physiological homeostasis
Chronic pain no longer signals damage to the body and is instead a detriment to the physical and psychological well-being of the sufferer.
Currently, psychological interventions for chronic pain target a variety of domains, including physical functioning, pain medication use, mood, cognitive patterns, and quality of life, while changes in pain intensity may be secondary
In order to articulate the distinct philosophies and effects of each psychological intervention, it is important to first consider the variety of ways that pain affects psychological functioning.
Psychological reactions to pain
Recurrent pain may contribute to development of maladaptive cognitions and behavior that worsen daily functioning, increase psychiatric distress, or prolong the experience of pain
Individuals suffering from chronic pain tend to show increased vulnerability to a variety of psychiatric conditions, including depressive disorders, anxiety disorders, and posttraumatic stress disorder. However, the relationship between depression and pain is likely bidirectional, as the presence of a major depressive disorder has been identified as a key risk factor in the transition from acute pain to chronic pain. Additionally, individuals with pain may suffer from significant anxiety and depressive symptomatology that does not reach the severity of a clinical diagnosis
Further, chronic pain negatively impacts quality of life and contributes to higher levels of disability.
Individuals with chronic pain are also vulnerable to
- higher rates of obesity,
- sleep disturbance, and
- show greater rates of medical utilization, and
- are vulnerable to problematic pain medication use.
Given the negative psychological consequences of chronic pain, it is worthwhile to consider three psychological mechanisms related to pain-related distress that have proven to be suitable targets for intervention: pain catastrophizing, fear of pain, and pain acceptance.
Pain catastrophizing is characterized by magnification of the negative effects of pain, rumination about pain, and feelings of helplessness in coping with pain. Pain catastrophizing has been associated with various forms of dysfunction, including increased rates of depression and anxiety, greater functional impairment and disability due to pain, and lower overall quality of life.
Pain-related fear is another psychological mechanism that has significant implications for physical and psychological functioning in chronic pain. Pain-related fear reflects a fear of injury or worsening of one’s physical condition through activities that may trigger pain. Pain-related fear is associated with increased pain intensity and increased disability. Pain-related fear contributes to disability by fostering passive or avoidant pain-coping behaviors that contribute to physical deconditioning and pain
Recently, there has been increased attention to the psychological flexibility model, which extends the fear-avoidance model of chronic pain and proposes to improve treatment outcomes through fostering of accepting attitudes towards pain
Psychological flexibility has been defined as an ability to engage in the present moment in a way that allows the individual to either maintain or adjust his or her behavior in the way that is most consistent with internally held goals and values; this idea is especially important in times of greater pain, given the narrowing of focus that is common during times of pain.
Similar to psychological acceptance, which fosters a nonjudgmental approach to distressing thoughts and emotions, pain acceptance is defined as
- a process of nonjudgmentally acknowledging pain,
- stopping maladaptive attempts to control pain, and
- learning to live a richer life in spite of pain
Pain acceptance influences emotional functioning through two distinct mechanisms:
- a willingness to experience pain, which buffers against negative emotional reactions to pain, and
- continued engagement in valued activities despite the presence of pain, which bolsters positive emotions
Pain acceptance has demonstrated positive associations with cognitive, emotional, social, and occupational functioning in chronic pain populations
Psychological intervention as an approach to pain management
Operant behavioral approaches
According to this theory, a behavioral drive to avoid pain leads individuals to avoid behaviors that are painful but maintain their physical and emotional health; this avoidance contributes to the development and maintenance of pain chronicity, deconditioning, and depression. Operant therapy for chronic pain utilizes reinforcement and punishment contingencies to reduce pain-related behaviors and foster more adaptive behaviors, including graded patterns of activity, activity pacing, and time-contingent medication management. Behavioral therapy for pain has shown positive effects on a variety of domains, including pain experience, mood, negative cognitive appraisals, and functioning in social roles
I can only imagine what “punishment” would be worse than the pain itself.
It’s dangerous to assume that quelling pain-related behaviors automatically equates with a decrease in suffering. Patients could just be suffering silently, not only from the pain itself, but from having it so casually dismissed as a more of a mental construct than a neurological and/or chemical dysfunction.
This becomes circular logic in that challenging this schema is perceived to be the very pain-related behavior that supposedly maintains the pain.
Consistent with exposure treatments for phobias and other anxiety disorders, in vivo exposure treatment for fear of pain involves development of a personalized, graded hierarchy of activities that elicit a fearful response, psychoeducation related to pain, fear, and behavior, and ultimately slow and systematic exposure to activities related to the individual’s fear hierarchy
Cognitive-behavioral therapy (CBT) adopts a biopsychosocial approach to the treatment of chronic pain by targeting maladaptive behavioral and cognitive responses to pain and social and environmental contingencies that modify reactions to pain.
CBT for pain develops coping skills intended to manage pain and improve psychological functioning, including structured relaxation, behavioral activation and scheduling of pleasurable events, assertive communication, and pacing of behavior in order to avoid prolongation or exacerbation of pain flares
Unlike operant-behavioral approaches, CBT for pain also addresses maladaptive beliefs about pain and pain catastrophizing through formal use of cognitive restructuring: identification and replacement of unrealistic or unhelpful thoughts about pain with thoughts that are oriented towards adaptive behavior and positive functioning
CBT for pain has been widely implemented as a standard treatment for pain and constitutes the current “gold standard” for psychological intervention for pain
CBT significantly improves disability and pain catastrophizing after treatment and yields longer-term improvements in disability, above and beyond the effects of usual medical care, as well as smaller effects on pain, catastrophizing, and mood when compared to no treatment. CBT-related changes in helplessness and catastrophizing are uniquely predictive of later changes in pain intensity and pain-related interference in daily functioning
The benefits of CBT for pain have been noted in many chronic pain populations but may not be as robust in some populations, including fibromyalgia.
This implies that CBT may only work for folks that don’t have a real disease, like Fibromyalgia, or CRPS, or even EDS. When the physical body is the origin of pain, changing thoughts with CBT will not help.
The intractable nature of chronic pain may make adaptation difficult as attempts to control pain may prove ineffectual, ultimately contributing to greater psychological distress
Recent efforts have thus expanded the cognitive-behavioral model of pain intervention to address these issues, which has yielded two newer treatment modalities:
- mindfulness-based stress reduction (MBSR) and
- acceptance and commitment therapy (ACT).
Unlike CBT, these approaches focus on fostering acceptance of chronic pain rather than emphasizing strategies for controlling pain, thereby improving emotional well-being and greater engagement in nonpain-related pursuits
Mindfulness-based stress reduction
Mindfulness-based interventions approach seeks to uncouple the sensory aspects of pain from the evaluative and emotional aspects of pain, and promote detached awareness of the somatic and psychological sensations within the body
MBSR is a form of meditation developed in Eastern philosophy and later adapted to Western intervention that enhances awareness and acceptance of physical, cognitive, and emotional states and disconnects psychological reactions from the uncontrollable experience of pain flares
MBSR promotes mindfulness through daily meditation, which is a requisite component of the treatment
meditations involve motionless sitting practices that expose participants to painful sensations in the absence of catastrophic consequences.
Unfortunately, even sitting still can have “catastrophic consequences” for a person with EDS, because the lengthy immobility allows the pressure of gravity to move joints out of alignment.
serve the additional purpose of increasing tolerance for negative emotions, thereby fostering more adaptive responses to pain
MBSR also reduces rumination and interoception of distressing physical signals and increases mindful awareness and acceptance of pain.
Unlike CBT, which identifies thoughts as distorted and in need of change, practitioners of mindfulness adopt a nonjudgmental approach to thoughts as “discrete events” that encourage emotional distance from thoughts.
Further, CBT is a goal-oriented treatment modality, targeting an increased relaxation response or an altered behavioral or thought response, whereas mindfulness does not prescribe specific goals, relying instead on nonjudgmental observation
MBSR has demonstrated efficacy in addressing the severity of medical symptoms and psychological symptoms, pain intensity, and coping with stress and pain; these treatment gains may last up to 4 years after intervention in many domains
None of the other therapies shows such prolonged aftereffects.
Acceptance and commitment therapy
ACT adopts a theoretical approach that thoughts do not need to be targeted or changed; instead, responses to thoughts may be altered so that their negative consequences are minimized
ACT interventions improve well-being through nonjudgmental and purposeful acknowledgment of mental events (ie, thoughts and emotions), fostering acceptance of these events, and increasing the ability of the individual to remain present and aware of personally relevant psychological and environmental factors;
In doing so, individuals are able to adjust their behavior in a way that is consistent with their goals or values, rather than focusing on immediate relief from thoughts and emotions
In the treatment of pain, ACT fosters purposeful awareness and acceptance of pain, thereby minimizing the focus on reducing pain or thought content and instead directing efforts towards fulfilling behavioral functioning. ACT shares conceptual similarity with MBSR due to shared goals of promoting mindfulness and acceptance of pain but, unlike MBSR, ACT does not utilize daily mindful meditation and instead focuses on identification of the values and goals of the individual, which serve to direct behavior
ACT-based interventions have demonstrated benefits on various aspects of mental health in chronic pain populations, including mental health quality of life, self-efficacy, depression, and anxiety. Some studies of ACT interventions for chronic pain have reported medium or larger effect sizes for improvements in pain-related anxiety and distress, disability, number of medical visits, current work status, and physical performance, with smaller effects of this intervention noted on pain and depression. However, meta-analytic studies of acceptance-based therapies for pain have revealed that ACT does not show incrementally greater efficacy in comparison to other established psychological treatments for chronic pain
Future directions and remaining questions
First, the effects of CBT are significant in the short term but are not consistently maintained across time, possibly due to decreased adherence
It is conceivable that acceptance-based approaches, which are predicated less on mechanistic coping strategies and instead foster accepting attitudes towards pain, may show greater rates of long-term adherence and longer-term benefits than CBT, though future study of this question is needed
Further, some pain disorders (such as fibromyalgia) have shown comparatively poorer treatment response to CBT than other pain disorders in some studies, which highlights the possible benefit of alternative interventions in such populations
Indeed, ACT and MBSR have also shown efficacy in fibromyalgia populations, though there remains a need to identify predictors of differential treatment response
Safety and tolerability of psychological therapies
Psychological therapies for pain are presumed to be at low risk for adverse effects to the recipient;
Some have suggested that patients who enter psychological treatment face risks of incorrect psychological diagnosis, psychological dependence, undermining of a patient’s ability to make their own decisions, or manipulation by the therapist to achieve nontherapeutic goals
There is a huge risk of patients becoming suicidal when a therapist tells them that “pain is all in your head so you should be able to control it with your mind.” While this may be factually true, this asks the patient to take on all the responsibility for the pain that has destroyed their life. This makes patients feel invalidated, devalued, and insulted.
Factors affecting the outcomes of psychological intervention
Practitioners should be cautioned against the assumption of homogeneity among patients with pain disorders, as a variety of factors may predict treatment response
The recent push to standardized, data-driven therapies destroys the individual customization of effective medicine.
Turk proposed that individuals coping with comparable levels of pain show distinct patterns of response that could be clustered into recognizable subclasses: “dysfunctional” patients, who report high levels of pain-related interference and distress; “interpersonally distressed” patients, who report lacking the support of loved ones in coping with their pain; and “adaptive copers,” who report notably higher levels of function and perceived social support and lower levels of pain-related dysfunction.
Turk proposed that these patient subgroups respond differently to psychological intervention, and subsequent findings have supported this idea: “dysfunctional” patients have demonstrated greater response to interdisciplinary treatment involving psychological care than “interpersonally distressed” patients.
Additionally, patients’ readiness to adopt a self-management approach to their own chronic pain appears to have significant implications for treatment response
patients who are in the precontemplation stage of treatment readiness may benefit more from insight-focused therapy, versus those in an action stage, who may benefit more from establishing relaxation-based and other active coping strategies
Additionally, there may be demographic, psychological, and medical differences among patients that are relevant to treatment response, including the etiology of pain conditions, socioeconomic status, and cultural and ethnic background; these factors require further empirical research in order to optimize clinical outcomes but have not yet received adequate attention in the clinical literature
In addition to being an important mechanism of treatment, there is evidence that baseline levels of fear of pain may also predict differential treatment response; individuals more fearful of pain at the outset of a multidisciplinary pain treatment program showed greater responsiveness to in vivo exposure for this problem
most of the connections between personality traits and variables relevant to psychological intervention for pain are theoretical and have not consistently emerged in empirical research
Yet, many in the pain management field rely on these theories and use them as though they were proven tools. Then, when the patient doesn’t respond favorably, the patient is blamed for “failing” the therapy, when in actuality, the therapy has failed them.
Psychotherapy constitutes a valuable modality for addressing the behavioral, cognitive, emotional, and social factors that both result from and contribute to pain-related dysfunction and distress through enhancement of self-management strategies
There are several distinct psychological interventions that differ in their theoretical approaches, therapeutic targets, and areas of efficacy, but CBT, ACT, MBSR, and operant behavioral approaches to pain may all play important roles for enhancing the self-management abilities of individuals with chronic pain
However, there remains a need to identify predictors of differential treatment response and salient patient subgroups to optimize treatment outcomes, as well as additional and alternative means to provision of psychological services for those who are unwilling or unable to engage in traditional psychotherapy.
Table 1 – Descriptions of psychological therapies for pain
Therapeutic modality Description of treatment Operant-behavioral therapy Treatment focuses on extinguishing maladaptive behavioral responses and fostering of adaptive behavioral responses to pain. Behavioral responses are altered through reinforcement and punishment contingencies and extinction of associations between threat value of pain and physical behavior. Cognitive-behavioral therapy (CBT) Treatment applies biopsychosocial approach to pain that targets behavioral and cognitive responses to pain. CBT protocols involve psychoeducation about pain, behavior, and mood, strategies for relaxation, behavioral pacing, behavioral activation, positive event scheduling, effective communication, and cognitive restructuring for distorted and maladaptive thoughts about pain. Mindfulness-based stress reduction Treatment promotes a nonjudgmental approach to pain and uncoupling of physical and psychological aspects of pain; teaches “nonstriving” responses to pain through experiential meditations and daily mindfulness practice intended to increase awareness of the body and proprioceptive signals, awareness of the breath, and development of mindful activities. Acceptance and commitment therapy Based on psychological flexibility model, treatment focuses on development of acceptance of mental events and pain and ceasing of maladaptive attempts to eliminate and control pain through avoidance and other problematic behaviors; emphasizes awareness, defusion, and acceptance of thoughts and emotions as well as behavioral engagement in pursuit of personal goals.
Table 2 – Demonstrated efficacy of psychological interventions by pain population
Therapeutic modality Pain disorder Operant-behavioral therapy Complex regional pain syndromes, lower back pain, mixed chronic pain, whiplash-associated disorders Cognitive-behavioral therapy Cancer, chronic lower back pain, chronic headaches, chronic migraines, chronic orofacial pain, complex regional pain syndromes, fibromyalgia, HIV/AIDS, irritable bowel syndrome, mixed chronic pain, nonspecific heart pain, multiple sclerosis, nonspecific musculoskeletal pain, osteoarthritis, rheumatoid arthritis, spinal cord injury, systemic lupus erythematosus, whiplash-associated disorders Mindfulness-based stress reduction Arthritis, cancer, chronic lower back pain, chronic headache, chronic migraine, complex regional pain syndromes, fibromyalgia, irritable bowel syndrome, rheumatoid arthritis, chronic neck pain Acceptance and commitment therapy Musculoskeletal pain (full body, lower back, lower limb, neck, upper limb), whiplash-associated disorders