Behavioral and Cognitive–Behavioral Approaches to Treating Patients with Chronic Pain: Thinking Outside the Pill Box

Abstract

Chronic pain is a prevalent and disabling problem. It is a complex, multifactorial disorder that requires a comprehensive biopsychosocial conceptualization. In this paper we provide an update on research implicating the importance of the behavioral and cognitive factors in chronic pain. In addition to the significant co-variations among self-reported symptoms, recent advancement in the imaging technology provides a better understanding of the neurophysiological basis of those psychosocial factors in chronic pain. Additionally, we discuss several variations of behavioral and cognitive-behavioral approaches to chronic pain, including operantbehavioral and cognitive-behavioral (including Acceptance and Commitment Therapy, internet-adapted, exposure based on the Fear Avoidance model) and review the evidence for their efficacy. Overall, the psychologically oriented programs based upon the biopsychosocial concept of pain are efficacious in reducing pain, disability, and mood disturbance. The accumulated evidence supports our contention that the conventional unidimensional, sensory perspective of pain based upon the biomedical model is, although ubiquitous and persistent, incomplete and inadequate to understand and effectively treat people with chronic pain. We must go beyond the convention of that pain is solely a neurophysiological phenomenon and start thinking outside the pill box if we hope to provide more effective treatment for people experiencing chronic pain.

Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy

“…In addition, medications used to treat pain (eg, steroids, opioids) may affect concentration, fatigue, self-perception, and the ability to engage in certain activities, further "clouding" the role of individual factors whose importance may shift over time. 101,113 These medications can also produce negative side effects, such as constipation and hyperalgesia. Interventions aimed at only some of these 3 core factors (ie, biological, psychological, sociocultural) are less likely to succeed.…”

Management of fibromyalgia syndrome in 2016

“…One of the most accepted behavioral therapy modalities in pain management is cognitive-behavioral therapy (CBT). CBT presents an inclusive therapeutic framework where it involves a range of both behavioral and cognitive modalities to address pain-related maladaptive coping, which is known to contribute to the pain modulatory system [105]. In general, research consistently shows that CBT, when given as a monotherapy, is effective in improving the specific target variables (e.g., maladaptive cognition, mood, QOL) [106][107][108] although the effects on the primary FM symptoms may be limited.…”

A Reduction in Pain Intensity Is More Strongly Associated With Improved Physical Functioning in Frustration Tolerant Individuals: A Longitudinal Moderation Study in Chronic Pain Patients

“…In relation to the latter, an increasing number of psychological factors are now gaining ground in the pain literature, including pain acceptance, coping, self-efficacy, and injustice (McCracken and Eccleston, 2003; Okifuji and Turk, 2015; Yakobov et al, 2018), among others, which suggests that there might be other potential moderators of the pain-to-health relationship in the pain literature. Also importantly, additional forms of irrational/rational thinking other than catastrophizing (Ellis, 1962), namely, demandingness (i.e., rigid requirements expressed in terms of “musts” and “shoulds”), low frustration tolerance (i.e., evaluating certain circumstances as unbearable), and self-downing (i.e., a tendency to make global negative self-evaluations) are starting to receive attention in pain research.…”