Cognitive Behavioral Therapy (CBT)

Background

  • Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) is a biobehavioral, evidence-based treatment for chronic pain that effects physiological changes via cognitive, emotional, behavioral, and lifestyle changes (e.g., sleep, nutrition, exercise). CBT-CP is distinct from CBT for depression, anxiety, and other conditions.
  • CBT-CP is recommended as a first-line treatment by the CDC, Joint Commission, Pain Task Force of the Academic Consortium for Integrative Medicine and Health, Institute of Medicine (now Academy), NIH Interagency Pain Research Coordinating Committee.
  • Because the central nervous system (CNS) regulates pain processing, the brain must be targeted in addition to the body to effectively treat acute and chronic pain (CP).
  • Thoughts, beliefs, memories, attentional processes, emotions, context, environment, social/family factors, sociocultural factors, and coping behaviors all contribute to pain construction and reduction.
  •  These processes occur via cortical and subcortical structures, e.g., limbic system, cerebral cortex, PFC. (See “How Pain Works”)
  • CBT-CP alters the negative cognitions, emotions (e.g., stress, anxiety, sadness, anger), physical sensations, and maladaptive coping behaviors that perpetuate the chronic pain cycle (see diagram below). Goals of treatment are to alter: 1) unhealthy thinking patterns; 2) negative emotions; 3) physical factors like muscle tension and SNS overactivity; 4) maladaptive coping behaviors like inactivity, isolation, and avoidance; 5) lifestyle habits including sleep, nutrition and exercise.
  • Research shows that targeting the components of this biopsychosocial cycle interrupts the neurophysiological processes that trigger and maintain pain, leading to increased functioning, less pain, + reduced suffering.

CBT Pain Cycle

Mechanism of Action:

  • CBT-CP changes the brain and body via neuroplastic and physiologic changes 
  • Changes in pain occur via a “gating” mechanism in brain and spinal cord – regulated by the limbic system, PFC, cerebral cortex, anterior cingulate cortex, anterior insula, and other cortical and subcortical structures – that amplifies/reduces pain signaling depending upon contextual, cognitive, and emotional input 
  • Increases in physical and social activity also associated with increases in endorphins, serotonin, and dopamine to regulate pain and mood
  • Cognitive and behavioral strategies like relaxation and mindfulness also turn off the sympathetic nervous system (SNS) stress response that amplifies pain, and reduce associated stress hormones + muscle tension. Changes in sleep, nutrition and exercise also directly impact brain + body.
  • CP is frequently comorbid with anxiety, depression, trauma and suicidality; these contribute to the development and maintenance of CP (see: "How Pain Works"). Targeting these comorbid conditions using CBT can also change pain.

Clinical Use:

  • Indications:
    • CBT should be utilized as a first-line treatment for all patients with chronic pain regardless of diagnosis, with or without psychiatric comorbidities, prior to or in concert with pharmacological interventions
    • Components of CBT (coping strategies, cognitive restructuring, sleep hygiene, etc.) have evidence of effectiveness across populations and ages, including children, adolescents, adults and older adults
    • Physicians should refer to multidisciplinary healthcare providers like pain psychologists, therapists trained in CBT-CP, physical therapists, and occupational therapists.
  • Best uses:
    • CBT and other nonpharmacological treatments should be recommended prior to and in concert with long-term pain medications 
    • Hospital departments should consider integrating a pain psychologist, PT, and OT for a multidisciplinary, coordinated approach to care
  • Dosage: 
    • Effective dose of CBT ranges across studies, average is typically 12 weeks but more is typically needed
    • CBT can be delivered via individual or group sessions, virtually or in-person

Special Considerations:

  • Contraindications: 
    • None: non-addictive, no side effects
    • Considering referring to longer-term therapy for complex trauma, suicidality, and addiction issues
    • Not all psychologists are trained in pain or CBT-CP. There are multiple resources (books, websites, etc.) available.
References: 

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Mayhew, M., Balderson, B. H., Cook, A. J., Dickerson, J. F., Elder, C. R., Firemark, A. J., ... & DeBar, L. L. (2023). Comparing the clinical and cost-effectiveness of remote (telehealth and online) cognitive behavioral therapy-based treatments for high-impact chronic pain relative to usual care: study protocol for the RESOLVE multisite randomized control trial. Trials, 24(1), 196.

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National Academy of Medicine (NAM). 2017. First do no harm: Marshaling clinician leadership to counter the opioid epidemic. Washington, DC: National Academy of Medicine.

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The Joint Commission. Joint Commission enhances pain assessment and management requirements for accredited hospitals. 2017; https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_ and_Management_Requirements_for_Accredited_Hospitals1.PDF

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U.S. Food and Drug Administration (FDA, 2017). FDA education blueprint for health care providers involved in the management or support of patients with pain (May 2017). 2017; https://www.fda.gov/downloads/Drugs/NewsEvents/UCM557071.pdf.

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Zeidan, F., Baumgartner, J. N., & Coghill, R. C. (2019). The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer. Pain reports, 4(4).

Author: 
Rachel Zoffness