Cognitive Behavioral Therapy in Pain Management

1. It is the patient’s preferred treatment source or treatment modality
2. Psychiatric and antidepressant drugs are contraindicated due to adverse reactions, side effects, or allergy
3. Other treatment modalities have been tried without success
4. Other treatment options are not appropriate for a particular patient
5. Patients may wish to experience emotional growth and healing while maintaining control
6. Patients are having a hard time overcoming negative moods and self-destructive behaviors associated with their pain disorder
7. Patients want to prevent a relapse of their condition or have a mechanism to better deal with a disorder if it should return after reducing or stopping medications or other treatment modalities
Pain management modalities often result in varying degrees of success, and patient descriptions of pain can sometimes be confusing, leading to what seems to be ineffective treatment or an inability to properly identify the most appropriate course or intervention. The complexities of influences that directly and indirectly influence both pain diagnosis and pain management therapy remain unprecedented. It is also virtually impossible to separate pain-producing disorders and pain management counseling from the realities of life and living experiences. Therefore, a host of conditions and issues, in addition to pain management treatment, that CBT may help to reduce or negate their negative influences are indicated in Table 8.2. The number of issues identified in Table 8.2 must also be addressed in order to achieve maximal results from CBT for treatment of pain scenarios since they cannot be removed, but will continue to negatively influence treatment attempts. In some severe cases, CBT may be more effective when it’s combined with other treatments, such as psychiatric medications.

Table 8.2

Other conditions and issues cognitive behavioral therapy may help address
Pain disorders
Sexual disorders
Bipolar disorder
Sleep disorders
Anxiety disorders
Marital and relationship problems
Grief and anger
Eating disorders
Substance abuse disorders
Work problems
Personality disorders
Psychotic disorders, such as schizophrenia
Medical illnesses, such as chronic fatigue syndrome
CBT for pain management treatment modalities is based upon a cognitive behavioral model of pain [3]. A most important concept is that the hallmark of this model contains the notion that pain and pain syndromes are complex experiences that are influenced by not only underlying pathophysiology but also an individuals’ cognitions, affect, and behavior [4]. CBT for pain management includes three basic components: (1) The first is a treatment rationale directed toward helping patients understand that cognitions and behavior can most certainly affect the pain experience and stresses to emphasize the role that patients can play in controlling their own pain. (2) The second component of CBT focuses on individual development and utilization of coping skills, training in psychological adaptation, and management. (3) The third component of CBT involves the application and continued maintenance of these learned coping skills.
Training can typically be provided in a wide variety of cognitive and behavioral pain coping strategies. Progressive relaxation and trigger or cue-controlled brief relaxation exercises are used to decrease muscle tension, reduce emotional distress, and divert attention away from pain or pain thoughts. Activity pacing and pleasant activity scheduling can also be used to help patients increase both the level and range of their relaxation and pleasant activity engagement. By providing patients with the appropriate tools, training in distraction techniques such as pleasant imagery, counting methods, and use of a focal point may help patients learn to divert attention away from severe pain episodes.
Another tool in the armamentarium of CBT is cognitive restructuring that is used to help patients identify and challenge overly negative pain-related thoughts and to replace these negative impressions or untoward thoughts with more adaptive, coping thoughts and skills. During the maintenance phase of learned coping skills, patients are encouraged to apply this newly learned behavior to a progressively wider range of daily situations. Patients can be provided with the skills necessary to engage in problem-solving methods that enable them to analyze and develop plans for dealing with pain flares or recurrence and other challenging situations when they begin or when pain becomes increasingly aggravating. Self-monitoring and behavioral contracting methods also are used to prompt and reinforce frequent coping skill practice. Psychological adaptation by the patient is a key factor in successful outcomes for mitigation of pain.
Although the treatment procedures of CBT described above can be used in managing acute pain, these same techniques are commonly used in the management of persistent pain [5]. In recent history, randomized, controlled studies have been carried out with a number of varying patient populations. As an example, Turner et al. demonstrated the usefulness of CBT in management of chronic low back pain, and CBT produced significant decreases in physical and psychosocial disability when compared to a waiting list control condition [6]. Several of the improvements reported by patients receiving CBT were maintained for periods of up to 12 months following treatment. Bradley et al. conducted a study of CBT in patients suffering from rheumatoid arthritis and found that CBT was superior to both a social support control and NO treatment control group in (1) reducing pain behavior, (2) decreasing intensity in disease activity, and (3) minimizing associated traits of anxiety [7]. In another early study, CBT was evaluated and identified to have great degrees of efficacy in managing osteoarthritis knee pain [8]. These authors went on to conclude that at post treatment, CBT produced significant reductions in pain and psychological disability relative to an arthritis education and standard care control conditions. Syrjala et al. have been able to demonstrate the efficacy of CBT in managing some forms of cancer-related pain [9]. Thus, a host of early evidence suggests that CBT is effective in treating both acute and chronic pain conditions such as back pain and persistent disease-related pain conditions such as arthritis and cancer.
Formal training in CBT for pain management is often available through workshops held at the American Pain Society, International Association for the Study of Pain, and the Association for the Advancement of Behavior Therapy. Several centers conducting trials of CBT also provide informal training, predoctoral training, psychology internship rotations, or postdoctoral fellowships in CBT pain management.

Five Steps (Typical) Involved in Cognitive Behavioral Therapy (Table 8.3)

Table 8.3

Stages of change and a clinician’s tasks
Patient’s stage
Clinician’s tasks
Increase the patient’s perception of the risks and problems associated with the current behaviors (raise doubt)
Evoke reasons for the patient to change, indicate risks of not changing; strengthen the patient’s self-efficacy for change of current behavior (tip the balance)
Help the patient to determine the best course of action to take in seeking change (begin to make it happen)
Help the patient to take steps toward change (relief)
Review progress; renew motivation and commitment as needed (sustenance)
Help the patient review the processes of contemplation, determination, and action without becoming stuck or demoralized because of relapse (perseverance)
Although there are different ways to conduct CBT, it typically includes five steps:


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Oct 18, 2015 | Posted by in General Dentistry | Comments Off on Cognitive Behavioral Therapy in Pain Management
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