Introduction

How can you cope when medications no longer ease the burning, stabbing, and throbbing sensations after an injury has healed? Can changing the way you think about pain reduce the pain itself? Chronic central pain, also known as central pain syndrome (CPS), is a complex neurological condition that causes persistent pain resulting from either injury or malfunction to the central nervous system (CNS). Often, with lingering, severe effects that are difficult to treat. The pain in CPS exceeds the physical impact of just “feeling pain”, extending its side effects to one’s sleep, emotional, psychological, and even functional health. 

As traditional medical treatments alone may be insufficient in managing the complexity of CPS, psychological interventions, in particular  Cognitive Behavioural Therapy (CBT), have emerged as a possible treatment. This article will explore how CBT and other psychological interventions are improving the quality of life for those affected by CPS and helping to regain control over their lives. 

Understanding chronic central pain 

What is it?

Chronic central pain, or CPS, is a neurological condition of ongoing pain caused by damage or dysfunction to the brain or spinal cord. It stems from increased neuronal excitability and synaptic transmission, despite limited input from the peripheral nervous system (PNS). The affected brain or nerve cells (neurons) remain in a hyperactive state, become highly sensitive, and amplify pain signals persistently. Most cases often happen after strokes, spinal cord injuries (SCIs), or multiple sclerosis (MS).¹ 

Common signs and symptoms 

The chronic, intense pain associated with CPS varies widely among people due to a variety of causes. It is often described as burning, stabbing, aching, or cutting. It may be constant or made worse by touch, movements, emotions, or cold temperature. Symptoms include numbness, tingling, severe itching, sensitivity to stimuli, and even sleep disturbances. The pain can either affect a large portion of the body or be restricted to specific areas, such as the hands or feet. It typically affects the areas below the site of CNS damage.¹  

Impact on emotions, relationships, and mental health 

CPS can deeply affect mental health, leading to depression, anxiety, and emotional distress. Persistent pain can strain relationships, reduce social engagement, and cause isolation. The emotional burden of chronic pain may lower self-esteem, disrupt communication, and cause frustration, making psychological support crucial for managing both physical and emotional impact. 

Why is it hard to treat? 

Due to the complexity and variability of symptoms depending on its CNS origin, CPS becomes resistant to standard therapies and traditional painkillers. With the integrated mind-body connection, emotional factors and neurological changes, treatment becomes further complicated, requiring a multidisciplinary and individualised approach for effective management. 

What is cognitive behavioural therapy (CBT)? 

Cognitive behavioural therapy (CBT) is a structured, goal-oriented and time-limited psychotherapy that focuses on how one’s thoughts and feelings are interconnected, and how they bring about our actions. Currently, it helps to identify and challenge negative thinking patterns and develop healthier responses to various emotional distress or mental health issues, including chronic pain. With active participation, clients can determine specific therapeutic goals towards skills learning and practising these individually under the guidance of the therapists to maximise effectiveness.² 

The main components of CBT are typically the combination of cognitive therapy, behavioural therapy, and mindfulness-based therapies.² 

• Psychoeducation: Learning the connection between thoughts, emotions, and behaviours
• Cognitive restructuring: Identifying automatic negative thoughts; challenging and replacing them with more balanced and realistic ones
• Behavioural activation: Encouraging engagement in meaningful activities to counteract withdrawal and low mood, despite pain or mood  
• Skills training: Teaching coping strategies like relaxation techniques, pacing activities, problem-solving, and stress management
• Homework and self-monitoring practice: Assignments between sessions for real-life skills application and reinforcing learning

How does CBT help with chronic central pain? 

Regarding the distressing nature of chronic central pain, CBT is a collaboration between the therapist and patient that helps to build psychological flexibility and improve emotional well-being using a tailored goal. Below is a more detailed CBT procedure for chronic central pain.^2,3

Psychoeducation 

Psychoeducation has been a crucial starting point of CBT for chronic central pain. It involves educating patients about how pain is processed in the brain, and how thoughts, emotions, and behaviours can influence its intensity and coping. By understanding the nature of central pain and the mind-body connection, individuals can gain insight into how stress, fear, and avoidance would amplify symptoms. This enables individuals to take an active role in therapy, reducing fear and promoting a sense of control and hope in managing their condition.⁴ 

Cognitive restructuring 

Cognitive restructuring in CBT can help individuals with chronic central pain in identifying and modifying distorted negative thoughts that potentially worsen their experience of pain. Patients with chronic pain can often develop habits such as catastrophizing; “I’ll never feel better”, overgeneralizing; “I cannot do anything anymore.”, or labelling; “I am a complete failure.” Through guiding questions and reflections led by therapists, individuals will learn to evaluate the evidence supporting or refuting their unhelpful thoughts, challenging their validity. Meanwhile, replacing them with more balanced and realistic ones like “ I have setbacks, but I am learning to cope with them.”  This reduces emotional distress, enhances pain tolerance, and improves overall functioning. 

Behavioural activation 

Behavioural activation is a key CBT step that encourages individuals with chronic central pain to re-engage themselves in meaningful and enjoyable activities gradually. Chronic pain can often lead to inactivity, low mood, and social withdrawal, which can intensify pain perception. Creating a schedule of valued activities that includes both daily essential tasks and enjoyable leisure activities counteracts inactivity and avoidance behaviours.

These tasks and activities are broken down into smaller, manageable steps, with gradually increased intensity and duration. This interrupts the cycle of avoidance and disability through rebuilding of daily routine while further helping to reduce focus on pain and improve mood. Ultimately, behavioural activation reinforces a sense of purpose, accomplishment, and control despite ongoing physical pain and other distressing symptoms.^5,6,7  

Skills training 

Skills training in CBT equips individuals with practical tools for more effective chronic central pain management. These include relaxation techniques like deep breathing and progressive muscle relaxation (PMR) that diminish tension and pain sensitivity. Activity pacing can prevent overexertion and flare-ups by balancing rest and movement. While problem-solving and goal-setting strategies are beneficial to foster a proactive mindset, mindfulness skills are also effective in improving awareness and reducing emotional reactivity. Not only can these skills benefit instant coping, but they also support long-term adjustment. Hence, promoting greater independence and emotional resilience. 

Homework and self-monitoring practice 

Amongst CBT for chronic central pain, homework, self-monitoring practices, and regular progress checks with therapists are essential for reinforcing skills and tracking improvement along the journey. Patients are encouraged to record pain levels, thoughts, triggers, and coping responses in their daily log during skills practices between sessions. These tools can facilitate the identification of trigger patterns, highlight progress, and guide adjustment in therapy.

Take-home tasks include relaxation exercises, activity pacing, or the application of cognitive techniques in real-life examples. Regular check-ins with therapists can not only ensure accountability but also celebrate small wins and fine-tune strategies to promote consistent engagement and long-term self-management for pain. 

Other psychological interventions for chronic central pain 

Despite CBT, several psychological interventions can also be used simultaneously as a supplement or for those patients where CBT alone is not responsive.

Mindfulness-based stress reduction (MBSR)

Mindfulness-Based Stress Reduction (MBSR) and CBT are both helpful in managing chronic pain, but in different ways. While CBT focuses on changing negative thoughts and behaviours, MBSR stresses non-judgmental awareness of the present moment, by teaching individuals to observe pain without reacting emotionally. Therefore, this reduces stress and pain intensity. This is especially useful in helping those overwhelmed by pain in building acceptance, emotional balance, and improving quality of life without challenging negative thoughts directly.^2,8 

Acceptance and commitment therapy (ACT)

Acceptance and Commitment Therapy (ACT) and CBT both stress improving functioning amid chronic pain, with ACT emphasising acceptance towards pain rather than changing negative thoughts. While CBT challenges negative beliefs, ACT encourages mindful awareness and commitment to personal values despite discomfort. ACT helps patients stop struggling with pain, reduce avoidance, and focus on meaningful life goals, making it effective for improving psychological flexibility and emotional well-being in chronic pain management.^2,9

Biofeedback

Biofeedback and CBT are both in service of reducing pain and improving functional outcomes through self-regulation. While CBT emphasises mindset shifting and practices of relaxation and pacing skills, biofeedback involves deliberate monitoring, observation of real-time physiological responses. Conscious control of responses can disrupt the pain cycle, making it effective for diminishing pain and improving functional outcomes.^2,10 

Hypnotherapy 

Hypnotherapy and CBT can both support chronic pain. CBT uses structured, conscious techniques in shifting mindset and behaviours. Hypnotherapy, as a heightened state of concentration and focused attention, uses guided relaxation to access the subconscious mind. Hypnotherapy can reduce pain perception, anxiety, and stress by promoting deep focus and altering pain responses, which is especially useful for patients open to mind-body techniques. It offers relief when combined with CBT as an alternative approach.^2,11

Challenges and limitations of psychological interventions 

Despite the meaningful relief, there still come some challenges, such as limited access to trained therapists and affordable therapy; patients’ resistance and stigma; time and effort required, co-existing mental health conditions, and even the variable outcomes. By which, client-centred, collaborative flexibility becomes the key to long-term success. 

Summary 

Chronic central pain has been a complex yet manageable neurological condition with psychotherapeutic tools like CBT, mindfulness, and others. These tools stress the psycho flexibility of humans by empowering them to take conscious control over their pain to enhance functionality and improve quality of life. It complements traditional medical or painkiller treatments with less harm and more focus on the mind-body connection and balance. 

While chronic pain may not disappear completely, these psychological interventions, when supplemented with traditional medical treatment, can still lead to a full and flourishing life despite chronic pain.