Cognitive-Behavioral Approaches to the Management of Chronic Pain

Over the past decade, pain practitioners have increasingly acknowledged the benefit of cognitive-behavioral approaches in the management of chronic pain, and have incorporated the intervention into their practice. This is directly related to positive outcomes with the approach, both experimentally and clinically.

There are a wide variety of cognitively-based interventions, but they all have basic commonalities. Bradley (1996) described assumptions underlying the cognitive approaches:

  1. Individuals actively process information regarding environmental events and internal stimuli. Using their learning histories and general information processing strategies, they appraise the meaning of events and develop expectations of the consequences that will follow potential responses.
  2. Cognitions interact with emotional and physiological reactions and behaviors. A person's thoughts, therefore, can change behavior because of its influence on emotional and physiological responses. The thoughts can also be influenced by physiological, emotional, and behavioral events.
  3. There is a reciprocal interaction between behavior and environmental responses. A person's behavior can be influenced by the environment, and behavior can, likewise, shape environmental events.
  4. For treatment to be effective, the cognitive, emotional, and behavioral dimensions must be addressed.

The basic premise underlying the use of cognitive-behavioral approaches for treatment of chronic pain is that expectations, attitudes, and beliefs affect the manner in which patients cope with their pain (Brownell, 1984). Behavior and affect are the result of the way in which a person construes the world, and psychological dysfunction in chronic pain patients is related to errors in cognition (Turk, Meichenbaum, and Genest, 1983; Lefebvre, 1986). It has been shown that patients who misinterpret their experience of pain are more severely disabled (Smith, Follick, Ahern, and Adams, 1986). Positive changes in one's cognition can help one to gain better control over the pain (Brownell, 1984). Therefore, one of the major goals in the intervention is to correct faulty thought processes that contribute to prolonged suffering and disability. Maladaptive beliefs should be replaced with new, more adaptive ones (Ciccone and Grzesiak, 1988).

ACUTE VS. CHRONIC PAIN

The cognitive approaches have been found useful in the management of both acute and chronic pain. Acute pain is of relatively short duration, and is usually accompanied by changes in autonomic activity. It warns the individual of pathology and assists the physician in diagnosis and treatment. Chronic pain, on the other hand, persists for prolonged periods of time, regardless of whether the precipitating factor has been adequately treated. Treatments initiated have not produced long term improvements in the condition. These patients typically have significant changes in their life, including life-style changes, financial strain, and decreased activity and physical deconditioning. These can result in depression and hopelessness (Sternbach, 1982; Lynch and Vasudevan, 1988). The focus of this chapter will be the use of cognitive-behavioral approaches in the treatment of chronic pain.

The components involved in cognitive-behavioral intervention include a thorough pain assessment, appropriate goal setting, the implementation of the techniques, and generalization of the technique.

ASSESSMENT

Pain is considered to be a subjective sensation of discomfort or distress. Pain includes nociception, which is the response of nociceptors to stimuli, its transmission along the peripheral axons to the dorsal root, and the transmission of it along the spinal thalamic tract to the midbrain. Finally, it culminates in the perception that includes interaction with the limbic system (Lynch, Kelly, and Vasudevan, 1992). Because pain is a psychophysiological process, the evaluation should focus on both the physical and psychological components of the experience. The evaluation is important in that it is the first contact of a patient with a person who will facilitate progress. In addition, it allows the clinician to assess the patient's status, and it sets a framework for which treatment can occur.

The psychological evaluation should assess the following dimensions: a) the current status of pain sensations, cognitions, pain behaviors, and mood; b) premorbid personality functioning; c) environmental factors that influence pain; and 4) the patient's strengths or internal resources (Degood, 1988). The assessment battery should consist of the clinical interview, administration of a structured pain inventory, and psychological testing. The clinical interview allows the clinician to assess the manner in which the person views the pain experience, what the person believes is causing the pain, and the treatments the person believes will be beneficial in alleviating the pain. Educational background, social history, psychosocial stressors, and vocational history can all influence success in a pain rehabilitation program and should be evaluated (Degood, 1988).

The are numerous structured pain inventories available for the assessment of the chronic pain patient. The inventories are designed to obtain information about the pain complaint and assess other psychosocial factors that may exacerbate or maintain the condition, such as financial stress or social reinforcement of pain behaviors. The objective paper-and-pencil measures, such as the MMPI-2, SCL-90, and Millon Behavioral Health Inventory, are useful in assessing personality characteristics which may affect treatment response as well as evaluate behavioral changes secondary to the pain. Brief paper-and-pencil measures, such as the State-Trait Anxiety Inventory and Beck Depression Inventory, are convenient for the clinician and the patient in that they can be administered throughout the treatment program and can provide indication of treatment response during various stages of intervention. An outline for the psychological evaluation is provided in Table I.

GOAL SETTING

Perhaps one of the most important aspects of treatment with the patient in chronic pain is the setting of appropriate treatment goals. Following the completion of the psychological evaluation, an adequate amount of time should be spent with the patient discussing the results of the evaluation, conceptualization of the problem, and setting treatment goals. The patient should be an active participant in this process. The patient needs to understand that treatment is a collaborative process; it will not be successful without their full cooperation. The goals should be measurable, specific, and made without any reference to the level of pain or subjective distress the person is experiencing. Appropriate goals should include the following (Degood, 1988):

  1. To have a reduction in the degree of subjective pain sensation;
  2. To have an improvement in emotional and behavioral functioning. Patients should monitor their thoughts, emotions and behaviors, and be able to recognize the relationship between these and the subjective experience of pain;
  3. Obtain maximum level of functioning, given limitations imposed by physical impairments;
  4. Decrease reliance on medications and utilization of the health care system to manage the pain.

TREATMENT APPROACHES

There are a wide variety of therapeutic techniques under the cognitive-behavioral model; however, they have commonalities. The interventions are action oriented, usually limited to a certain period of time, and are very structured. They can be administered in either an individual or group setting (Turk, Meichenbaum, and Genest, 1983). The pain will not be eliminated by the intervention, but the individual will have the necessary coping skills to deal with it more effectively. With the approach, patients learn to live more satisfying lives, despite the presence of physical discomfort. A message emphasized to patients is that they are not helpless in dealing with their pain and it should not control their lives (Turk and Meichenbaum, 1984). Some practitioners utilize cognitive approaches solely, which deal with thought processes, while others integrate behavioral approaches, such as relaxation, into the program.

Turk et al. (1983) described their cognitive-behavioral approach to the management of chronic pain:

  1. A conceptual framework of viewing pain is provided to the patient. This includes a description of the manner in which thoughts and feelings can influence the pain.
  2. Patients learn specific methods of dealing with pain. Examples of techniques utilized include the following (Turk and Genest, 1979):
    • Imaginative inattention: The person imagines scenes that are incompatible with pain, such as having a picnic in the park during the springtime.
    • Imaginative transformation: Relabel pain sensations as being less distressing. For example, the patient imagines sensations of warmth or numbness.
    • Transformation of context: Imagine the sensations as occurring in different, more appropriate context, such as building a snowman.
    • Attention diversion

    Internal: Attend to alternative thoughts, such as a pleasant song.
    External: Attend to alternative external event, such as focusing on an object.
    Four steps are involved in incorporating the coping strategies

    1. Prepare the person for minor painful sensations;
    2. Being able to confront the pain as its severity increases;
    3. Coping effectively with the feelings that tend to exacerbate pain, such as anxiety or frustration; and
    4. Learning to reinforce one's self for successfully coping with the pain experience.
  3. Generalization of skills to situations outside the clinical setting are facilitated by initially practicing/rehearsing them in the laboratory setting and then utilizing them in the natural environment. Generalization is fostered throughout treatment by guided exercise and homework assignments. These techniques are aimed at increasing the patient's self-efficacy. The rehearsal allows the clinician to identify and handle difficult situations that might arise. There should also be discussion of relapse, and the patient should be taught ways of dealing with that, if it occurs. Throughout treatment, the patient is encouraged to evaluate progress and review homework assignments (Turk and Meichenbaum, 1984).

Ciccone and Grzesiak's (1988) approach differs from the one developed by Turk and associates. It is their postulation that the psychological dysfunction observed in chronic pain patients is largely related to cognitive error. Patients who tend to misconstrue or misinterpret the meaning of the pain experience are usually more severely disabled. Support for their postulation came from a study conducted by Smith, Follick, Ahern and Adams (1986), in which they examined the thought patterns of chronic back pain patients. In their study, the patients who tended to overgeneralize their pain experienced more debilitating pain symptoms than those who did not. In addition to overgeneralization, cognitive errors include "demandingness, awfulizing, self-downing, and low frustration tolerance." The extent to which a person experiencing pain becomes disabled is directly related to that person's perception and subsequent evaluation of the pain. It is their belief that, with the exception of
pain arising from ongoing nociception, all the symptoms of chronic pain can and should be explained in purely cognitive terms.

Ciccone and Grzesiak's approach involves using careful cognitive analysis to identify specific errors in thinking that need to be corrected. The modality utilized in accomplishing this is rational-emotive therapy, a therapy formalized by Albert Ellis (1962). The goal of treatment is to make a "profound" change in the way the patients think. The cognitive errors that are responsible for eliciting the patient's symptoms are targeted in the intervention. Verbally challenging patients to defend their irrational beliefs is a way of accomplishing this. In order for this approach to be effective, the patient has to be willing to accept cognitive change. Treatment offered and initiated without a patient's consent may adversely affect the therapeutic relationship and therefore make it difficult for other changes to occur.

RESEARCH

There are numerous strategies identified under the cognitive-behavioral umbrella. The studies have shown the effectiveness of cognitive-behavioral approaches in the management of chronic pain. However, research thus far has failed to indicate which cognitive strategy is most effective in changing perceptions (Pearce, 1983).

Nicholas, Wilson, and Goyen (1992) evaluated the relative efficacy of a cognitive-behavioral group treatment plus physiotherapy to attention-control therapy plus physiotherapy. In the cognitive-behavioral intervention, a model of chronic pain and its consequences was presented. The model focused on goal-setting, increasing activity, changing negative, maladaptive cognitions, medication reduction, and attention diversion. The cognitive-behavioral approach plus physiotherapy group had significantly more improvement at posttreatment on measures of "other-rated" functional impairment, the use of active coping strategies, medication usage and self-efficacy beliefs; however, the groups did not differ in changes on self-report measures of disability, pain intensity, depression and pain beliefs. The superiority of the cognitive-behavioral approach plus physiotherapy over the attention-control and physiotherapy condition slightly diminished at follow-up.

Turner and Jensen (1993) conducted a study evaluating the efficacy of cognitive therapy in treating low back pain patients in an outpatient group setting. They compared cognitive therapy techniques with relaxation training, a treatment that had previously demonstrated effectiveness. They directly compared the two methods and then compared each method with an intervention consisting of both methods. Compared to the waiting-list control condition, patients in all three treatments (cognitive therapy, relaxation training, cognitive therapy and relaxation training combined) had significant improvement in self-reported pain intensity from pre-treatment to post-treatment. Both cognitive therapy and relaxation training were found to influence self-reported pain similarly. All groups, including the waiting-list control condition, showed significant improvement in disability, cognitive errors, and depression. All gains made in the three treatment groups from pre- to post-treatment were maintained at the 6- and 12-month follow-up.

Bergdahl et al (1995) evaluated the effectiveness of cognitive therapy in treating resistant burning mouth syndrome, a condition consisting of burning and painful sensations in the mouth when the mucosa is clinically normal. Thirty patients participated in the study, and were randomly placed in either the treatment group or the attention / placebo group. Patients treated in the cognitive group were seen once weekly for 12-15 sessions lasting one hour, while the placebo group patients had three return visits during the 12-15 week period. The goal of their cognitive approach was consistent with the literature; to replace dysfunctional cognitions with more realistic ones. The therapist assisted the patients in identifying, reality-testing, and correcting dysfunctional beliefs regarding their suffering. The intensity of the pain was significantly reduced in the treatment group at the post-treatment measurement point and was further reduced at the 6-month follow-up. The burning mouth syndrome intensity in the attention/placebo group remained at the same level at the end of treatment.

Sanders et al (1989) examined the efficacy of cognitive-behavioral therapy in treating nonspecific recurrent abdominal pain in 16 children. The study utilized a controlled design and compared the cognitive-behavioral treatment program to a waiting-list control group. The treatment consisted of two components: a cognitive coping skills component and a behavioral component. The cognitive component included self-monitoring, self-efficacy statements, self-instruction, imagery and relaxation, and self-reward. The behavioral component consisted of self-monitoring of the pain, competing activities, and a differential reinforcement of other behavior schedule for increasing pain-free periods and prompting distraction. Although both groups improved on child and parent measures of pain over the course of the study, the treatment group responded faster and their effects generalized more to the school setting. Additionally, a larger number of them reported being pain-free at the three-month follow-up.

Turner (1982) conducted a study that evaluated the relative effectiveness of relaxation training and cognitive-behavioral intervention with a relaxation component in the treatment of chronic low back pain patients in a group setting. Although the cognitive-behavioral intervention that included relaxation was superior on some of the measures, both treatments were associated with improvement in psychosocial and physical disability.

Rybstein-Blinchik (1979) also evaluated the effectiveness of various cognitive methods and a control group in treating 44 inpatients with diverse diagnoses. The three treatment groups consisted of somatization condition, irrelevant condition, and relevant condition. In the somatization condition patients were told to substitute the phrase 'a certain feeling' for the word 'pain' and to analyze sensations that accompanied that 'certain feeling'. Patients in the irrelevant condition were told to use thoughts concerning important events in their life to replace the current thoughts that were associated with their pain experience. Patients in the relevant condition were instructed to reinterpret their pain experience. For example, instead of feeling pain, one would think 'I feel numbness'. Control group patients engaged in conversation about their pain problem.

Following treatment, patients in the relevant condition endorsed significantly milder and fewer affective, evaluative, and sensory words on the McGill Pain Questionnaire to describe their pain compared to the other groups. The relevant group had significantly lower ratings of pain intensity than those of the somatization and control groups. The relevant group also obtained significantly lower ratings of pain intensity than patients in the somatization and control groups. The study failed to provide data on transfer of techniques outside the therapy setting or follow-up data.

Mitchell and White (1977) evaluated the different components of cognitive-behavioral techniques to determine their relative contribution in reducing migraine headache activity. All twelve patients received the first intervention which consisted of keeping a record of headache frequency throughout the treatment program. They were also randomly assigned to one of four treatment conditions. Three patients received no further treatments and nine participated in self-monitoring. Six of the nine were assigned to a skills acquisition stage 1 group, which consisted of learning to apply learned relaxation techniques to stressful situations. Three of these patients received training in further stress coping techniques, such as thought stopping and assertiveness training.

Significant reductions in headache activity were obtained after skill acquisition stage 1, and further decreases were observed after stress coping techniques were introduced. The results were maintained at the 12-week follow-up. Self-recording and self-monitoring alone failed to provide substantial decreases in headache activity.

Spence (1989; 1991) reported on two studies that examined the effectiveness of cognitive behavioral intervention in the treatment of chronic, upper extremity pain, and at the 2-year follow-up. The study compared the effectiveness of group versus individual cognitive-behavioral therapy. The subjects were randomly assigned to either an individual cognitive-behavioral therapy, group cognitive-behavioral therapy, or a waiting-list control group. The cognitive-behavioral therapy consisted of goal setting, cognitive restructuring, relaxation and biofeedback training, cognitive coping skills, such as attention diversion, stimulus control, and communication and assertiveness skills.

Significant improvements were observed in both treatment groups on measures of depression, anxiety, coping distress, impact on daily living, and subjective pain and distress. These improvements were not observed in the control group. The results were maintained at the 6-month follow-up. At the 2-year follow-up, significant improvements, compared to the pre-treatment levels, were maintained on measures of depression, coping strategies, significant other measure of disability, and subjective pain and distress. The individual treatment condition showed some relapse at the follow-up on measures of self-reported pain and interference in daily activity. Otherwise; there was minimal difference observed between the two treatment conditions at the two year follow-up.

In summary, both clinical experience and the plethora of research provide support for the cognitive-behavioral approaches in the management of chronic pain, on both short and long-term basis. However, in order for the intervention to be most effective, the clinician must work in collaboration with the patient.

REFERENCES

Bergdahl, J., Anneroth, G., and Parris, H. (1995). Cognitive therapy in the treatment of patients with resistant burning mouth syndrome: A controlled study. Journal of Oral Pathology and Medicine, 24, 213-215.

Bradley, L.A. (1996). Cognitive intervention strategies for chronic pain: Assumptions underlying cognitive therapy. Southern Pain Society News, April 1996, 12-13.

Brownell, K.D. (1984). Behavioral medicine. Annual Review of Behavioral Therapy, 9, 180-210.

Ciccone, D.S. and Grzesiak, R.C. (1988). Cognitive therapy: An overview of theory and practice. In N. Lynch and S. Vasudevan (Eds.), Persistent pain: Psychosocial assessment and intervention. Boston: Kluwer Academic Publishers.

Degood, D. (1988). A rationale and format for psychosocial evaluation. In N. Lynch and S. Vasudevan (Eds.), Persistent pain: Psychosocial assessment and intervention. Boston: Kluwer Academic Publishers.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Lefebvre, M.F. (1986). Cognitive distortion and cognitive errors in depressed psychiatric and low back pain patients. Journal of Consulting and Clinical Psychology, 54, 222-226.

Lynch, T.N., Kelly, J.F., and Vasudevan, S.V. (1992). Psychological examination and psychometric testing. In P. P. Raj (Ed.), Practical management of pain. St. Louis: Mosby-Year Book.

Mitchell, K.R. and White, R, G. (1977). Behavioral self-management: An application to the problem of migraine headaches. Behavior Therapy, 8, 213-222.

Nicholas, M.K., Wilson, P.H., and Goyen, J. (1992). Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain, 48, 339-347.

Pearce, S. (1983). A review of cognitive-behavioral methods for the treatment of chronic pain. Journal of Psychosomatic Research, 27, 431-440.

Rybstein-Blinchik, E. (1979). Effects of different cognitive strategies on chronic pain experience. Journal of Behavioral Medicine, 2, 93-101.

Sanders, M.R., Rebgetz, M., Morrison, M., Bor, W., Gordon, A., Dadds, M., and Shepherd, R. (1989). Cognitive-behavioral treatment of recurrent nonspecific abdominal pain in children: An analysis of generalization,maintenance, and side effects. Journal of Consulting and Clinical Psychology, 57, 294-300.

Sternbach, R.A. (1982). The psychologist's role in the diagnosis and treatment of pain patients. In J. Barber and C. Adrian (Eds.), Psychological approaches to the management of pain. New York: Brunner / Mazel.

Smith, T.W., Follick, M.J., Ahern, D.K., and Adams, A. (1986). Cognitive distortion and disability in chronic low back pain. Cognitive Therapy and Research, 10, 201-210.

Spence, S.H. (1989). The differential effectiveness of group versus individual applications of cognitive-behavioural therapy in the management of chronic, occupational pain of the upper limb. Behavior Research and Therapy, 27, 435-446.

Spence, S.H. (1991). Cognitive-behavior therapy in the treatment of chronic, occupational pain of the upper limbs: a 2 year follow-up. Behavior Research and therapy, 29 503-509.

Turk, D., and Genest, M. (1979). Regulation of pain: The application of cognitive and behavioural techniques for prevention and remediation. In P.C. Kendall and S.D. Hollon (Eds.), Cognitive-behavioural interventions: Theory, research and procedures. New York: Academic Press.

Turk, D.C., Meichenbaum, D., and Genest, M. (1983). Pain and behavioral medicine: A cognitive-behavioral perspective. New York: The Guilford Press.

Turk, D.C. and Meichenbaum, D. (1984). A cognitive-behavioral approach to pain management. In P.D. Wall and R. Melzack (Eds.), Textbook of pain. New York: Churchill Livingstone.

Turner, J. A. (1982). Comparison of group progressive-relaxation training and cognitive-behavioral group therapy for chronic low back pain. Journal of Consulting and Clinical Psychology, 50,757-765.

Turner, J.A. and Jensen M.P. (1993). Efficacy of cognitive therapy for chronic low back pain. Pain, 52, 169-177.

Vasudevan, S.V. and Lynch, N.T. (1988). Counseling the patient with chronic pain: The role of the physician. In N. Lynch and S. Vasudevan (Eds.), Persistent pain: Psychosocial assessment and intervention. Boston: Kluwer Academic Publishers.

TABLE I

PSYCHOLOGICAL EVALUATION OUTLINE

Purpose of Psychological Evaluation

To identify and assess factors that might contribute to the experience of pain

Factors that can adversely affect the patients response to treatment
Problems secondary to the pain complaint

To assist in identifying a responsible set of treatment goals and to formulate a plan to meet the goals

Areas to Assess

Evaluative aspects of pain

Meaning of pain to the patient

Affective

Depression

Anxiety

Psychosocial Stressors

Effects on pain on functioning level

Background Information

Early developmental experiences

Previous medical and psychiatric history

Medication use or abuse

Secondary gain

Financial compensation

Reinforcement of pain behaviors

Avoidance of unpleasant activities

Reinforcement from significant others

Patient's resources

Education/vocational background

Support from family and employers

Methods of Evaluation

Clinical Interview - Interview patient and significant others

Structured Pain Inventories

Psychosocial Pain Inventory

McGill Comprehensive Pain Questionnaire

Objective Paper-and-Pencil measures

Minnesota Multiphasic Personality Inventory-2 (MMPI-2)

Millon Behavioral Health Inventory

Symptom Checklist-90

Beck Depression Inventory

State-Trait Anxiety Inventory

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