Cognitive and Behavioral Pain

Management
Judith B. Chapman,
Ph.D., ABPP
Behavioral Medicine
Program

Traditional disease model of pain

Psychological and social factors viewed as
reactions to disease and trauma
View of pain conditions as either organic or
psychogenic in etiology

How to explain
For

up to 80% of persons complaining of low

back pain, no physical basis can be identified
(Deyo, 1986)

Expression

of pain symptoms, related

psychological distress, and extent of disability
are at best only moderately correlated with
observable pathophysiology (Waddell & Main, 1984).

Biopsychosocial Model

Biological factors initiate, maintain, modulate physical

changes

Psychological factors influence appraisal, perception

of internal physical signs

Social factors shape the behavioral responses of

patients to the perception of physical changes

Which psychological factors

influence pain?
Cognitive

(Pain Beliefs, Cognitive Errors, Self

Efficacy, Coping)

Affective
Personality

Pain Beliefs
Anxiety Sensitivity
Some patients may be hypersensitive and experience
a lower threshold for labeling stimuli as noxious
(Asmundson, Bonin, Fromback, & Norton, 2000)

Learned Expectation
About 83% of patients with LBP were unable to
complete a movement sequence because of
anticipated pain, 5% unable because of lack of ability
(Council, Ahern, Follick, & Cline, 1988).

Pain Beliefs
Patients beliefs about pain or disability are better
predictors of ultimate level of disability than are
physician ratings of disease severity

Self Efficacy
- a personal conviction that one can complete a
course of action to produce a desired outcome
Low self efficacy ratings of pain control are
related to low pain tolerance (Dolce, Crocker,
Moletteire, & Doleys, 1986)

The Efficacious Person

Experiences

less anxiety and physiological

arousal when experiencing pain

Is

better able to use distraction

Can

persist in the face of noxious stimuli

(stoicism)

Cognitive Errors
a negatively distorted belief about oneself or
ones situation
Examples: Catastrophizing, overgeneralization,
selective abstraction

Consequences of catastrophizing
Among postsurgical patients, those with a
greater frequency of catastrophizing thoughts
had a greater number of pain complaints and
required significantly more pain medications
(Butler, et al., 1989).

Coping Style
Active

coping (distraction, reinterpreting

sensations, stoicism) is associated with greater
activity and better mood

Passive

coping (wishful thinking, relying on

others) is correlated with greater perceived
pain and depression

Affective Factors
40-50%

of chronic pain patients experience

depression
About half report feelings of anger, irritability
Both are associated with perception of
increased pain severity, greater pain
interference, lower activity level

How do personality disorders fit in?

No

specific personality disorder is associated

with poorer coping with pain

However,

the presence of any personality

disorder predicts less adaptive coping

Palo Alto Pain Clinic Demographics

Average

age 56 years (range 20-87)

88% male
87% Caucasian (6% African American, Hispanic; >1%
Asian, Native American)

61%

Predominantly Musculoskeletal Pain

(30% neuropathic, 3% visceral, 7% other)

Palo Alto Pain Clinic Data

75%

depressed
33% report active suicidal thoughts
48% report a history of trauma
19% meet criteria for PTSD

Pain Clinic Follow-up Data

At two and six month follow-up, patients reported a
significant decrease in pain severity and a significant
decrease in pain interference
Changes seen across diagnostic and demographic
groups (age, type of pain, presence of significant
mental disorder)
No significant overall change in mood, sleep, or activity
level

Older patients
Reported

significantly less pain severity than

young
Less pain interference
Better overall sleep
Less depression

Aging and Pain

Changes

in visceral sensations with age

Increased prevalence of post-herpetic
neuralgias
Nonlinear relationship between joint pain and
age

Cognitive-behavioral Treatment
Enhancing

motivation
Relaxation exercises
Education about Sleep Management
Hypnosis and Imagery
Cognitive Therapy
Family Interventions

Principles of Motivational
Enhancement Therapy
Expressing

empathy
Developing discrepancy
Avoiding arguments
Rolling with resistance
Supporting self efficacy

Relaxation Strategies
Progressive

muscle relaxation
Deep (diaphragmatic) breathing
Biofeedback
Autogenic training

Caveats and contraindications

Psychotic

patients
Relaxation-induced anxiety
Panic attacks

Hypnosis
A

state of highly focused attention in which

there is an alteration of sensations, awareness,
and perceptions
Reduces pain through attention control and
distraction

Essential Components of Hypnosis

Physical

relaxation
Deepening exercise
Pleasant imagery
Suggestion
Post-hypnotic suggestion
Gradual return to alertness

Sleep and Pain

Pain

severity and opioid use does not predict

sleep problems; depression does
Sleep medications seem to have no impact on
depression or pain severity
Sleep med use was highly correlated with
poorer sleep quality, poorer sleep duration, and
poorer sleep efficiency (Chapman, Lehman, Elliott, and
Clark, In Press).

Sleep Management Guidelines

Go

to bed when sleepy

Do not remain in bed if not sleeping
Bed as cue for sleep
Have regular wake-up time
Avoid evening use of ETOH, caffeine,smoking
Exercise in AM, rather than at night
Arrange relaxing nighttime routine

Cognitive Therapy
Identify

and monitor pain-relevant cognitions

Notice emotional consequences of negative
cognitions
Learn how to challenge maladaptive cognitions
or consider probability bad events may occur
Assertiveness training
Value of self reinforcement

Goals of Family interventions

Recognition of operant principles as they relate to pain

behaviors
Altering patterns of pain-relevant communication
Increase time spent in non-pain related conversation
Increase frequency of pleasurable family activities
Recognition/treatment of depression in other family
members

Who doesnt benefit from CBT for

pain?
Cognitively

disorganized
Patients with little- no motivation to use
strategies
Severe anxiety or depressive disorder
Active substance abusers

Pain may be inevitable, but misery

is optional
Greatest Limitation of
CBT for Pain
-

Compliance with
successful strategies
decreases over time

- No benefit when not

practicing

Best Recommendation
Relapse Prevention should
be part of the therapy
Encourage booster
sessions 6-12 months
after therapy ends