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Section 5
Chronic Pain Management & Psychological
Approaches Part II

Question 5 | Test | Table of Contents

Cognitive–behavioral approaches
Patient behavior is an important aspect in the development and maintenance of chronic pain and pain-associated disability (McCracken & Eccleston 2003). Behavior theory defines pain by the presence of ‘pain behaviors’ (Fordyce 1976, 1986). Pain behaviors are verbal and non-verbal signs of distress that are independent of subjective report. Early interpretations focused upon ‘overt’ behaviors such as staggering and grimacing and environmental contingencies whereas more recent approaches to this model have acknowledged the effects of biological and psychological variables on behavior. The behavioral framework has expanded to incorporate coping, and latterly, to include acceptance of chronic pain. Pain behaviors are believed to be instrumental in the development of avoidance of activity, which then also becomes a pain behavior (Waddell &Turk 1992). Therefore an important aim of rehabilitation is to increase physical and functional ability. Interventions with a behavioral component include exercise which is an effective major component of most, if not all, pain management and rehabilitation programs. Goal setting and pacing are also behaviorally based techniques that can be used to increase and sustain physical and functional activity. These techniques are reviewed in the second paper.

Cognitive theory examines constructs such as expectations and beliefs about pain, personal control, problem-solving abilities and coping skills (Gamsa 1994). Cognitive models make a clear statement about the relationship between cognition, affect and behavior. They are usually subsumed under the cognitive–behavioral model because cognitive processes and behavior are intricately linked. The assumption of cognitive models of pain is that cognitive activity and an individual’s emotional distress or behavioral difficulty is not a direct reaction to an untoward life event but rather a consequence of how that event is perceived.

Cognitive assessment and intervention to control pain attempt to increase patients’ self-efficacy. It involves identifying those dysfunctional thought processes and irrational beliefs that lead to emotional distress and which increase pain perception and experience. Cognitive events which amplify pain syndromes have been found to include catastrophizing, over-generalization, low frustration tolerance, external locus of control and mislabeling of somatic sensations (Ciccone & Grzesiak 1984).Thus the focus of the cognitive approach to treatment is to change the way individuals think about their pain.

In the cognitive–behavioral approach, the behavioral model is expanded to incorporate cognition and affect within behavioral therapy. It views the way in which individuals react to pain as a complex multidimensional response, though does not offer a model of the cause of the pain.

A variety of psychological interventions are combined within this framework which emphasizes education, control by patients and coping strategies. Cognitive–behavioral therapies consider the cognitive effects on behavior and attempt to change physiological responses through the manipulation of cognitions. CBT helps patients to identify and modify maladaptive beliefs and behaviors and use adaptive coping strategies to manage their condition (Turner et al. 2001) and usually comprises a combination of cognitive and behavioral interventions such as education, acquisition of coping skills and operant conditioning. Historically, there has been a tendency for cognitive–behavioral interventions to be dominated by behavioral components. In response to this, Sharp (2001) has offered a re-formulated cognitive– behavioral therapy model which focuses more directly on patients’ thoughts about and appraisals of, their pain based upon suggestions that the relationship between pain and arousal is mediated by appraisal.

Cognitive–behavioral approaches are used extensively in pain programs with some evidence of effectiveness in restoring function and mood and reducing pain and disability- related behavior (Harding & Williams 1995, Morley et al. 1999). The latter authors carried out a systematic review and meta-analysis of 25 randomized controlled trials of cognitive–behavioral therapy and behavior therapy for chronic pain in adults and concluded that active psychological treatments based on the principle of cognitive–behavioral therapy were effective. Several theories have been suggested as mediating the efficacy of cognitive–behavioral therapy. These include a reduction of the stress response by increasing control and reduction of fear, closure of the proposed gating mechanism to painful stimuli physically by postural correction and psychologically by reduction of anxiety and fear. Disruption of reverberatory neural activity, activation of the endogenous pain control system and a reduction of pain associated with immobility by stretching and exercising muscles appropriately have also been suggested (Adams 2004, Zusman 2004).

The primary aims of cognitive–behavioral therapy are:
1) To help patients to alter counterproductive beliefs that their problems are unmanageable, i.e. help them to become resourceful problem solvers and enable them to cope effectively with their pain, emotional distress and psychosocial difficulties.

2) To assist patients in learning to monitor their thoughts, emotions and behaviors and to identify relationships between these factors and environmental events, pain, emotional distress and psychosocial difficulties.

3) To teach patients to develop and maintain effective and adaptive ways of thinking, feeling and responding, which can be used to cope with any recurring problems that may be experienced after treatment has ended such as problem solving in everyday activities and reduced catastrophizing regarding any increase of pain, for example, after activity. The idea is to maintain any gains resulting from treatment.

4) To teach patients to perform behaviors such as relaxation techniques, postural correction and exercise at appropriate times in order to cope effectively with pain, emotional distress and psychosocial difficulties and reduce dependency on medication. This is particularly applicable to nurses and other health professionals as levels of physical fitness, mobility and posture and thus increasing ability to perform functional abilities, can be improved through a graded exercise program as part of a pain management program. Relaxation skills to improve the ability to manage stress may also be taught.
- Adams, Nicola, Poole, Helen & Clifford Richardson; Psychological approaches to chronic pain management: part I; Journal of Clinical Nursing; Mar 2006; Vol. 15; Issue 3.

Personal Reflection Exercise #2
The preceding section contained information about chronic pain management and psychological approaches part II.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Which Outcome Variables are Associated
with Psychological Inflexibility/Flexibility
for Chronic Pain Patients?
A Three Level Meta-Analysis

Fang, S., & Ding, D. (2022). Which outcome variables are associated with psychological inflexibility/flexibility for chronic pain patients? A three level meta-analysis. Frontiers in psychology, 13, 1069748.

Peer-Reviewed Journal Article References:
Chen, S., & Jackson, T. (2018). Pain beliefs mediate relations between general resilience and dysfunction from chronic back pain. Rehabilitation Psychology, 63(4), 604–611.

France, C. R., Ysidron, D. W., Slepian, P. M., French, D. J., & Evans, R. T. (2020). Pain resilience and catastrophizing combine to predict functional restoration program outcomes. Health Psychology, 39(7), 573–579.

Noyman-Veksler, G., Shalev, H., Brill, S., Rudich, Z., & Shahar, G. (2018). Chronic pain under missile attacks: Role of pain catastrophizing, media, and stress-related exposure. Psychological Trauma: Theory, Research, Practice, and Policy, 10(4), 463–469.

QUESTION 5
What is the assumption of cognitive models of pain? To select and enter your answer go to Test.

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