Cognitive Behavioural Therapy For Chronic Pain

Overview

Chronic pain is a condition described as recurrent or persistent pain lasting longer than 3 months.¹ It can be a result of injury, disease, or, in many cases, the underlying cause is unclear. It is a major burden on society, estimated to affect 20-50% of the global population.² Chronic pain is not only taxing on your physical health but can also be mentally draining and emotionally distressing.3 Currently, there are many medicinal and therapeutic interventions available. However, patients often discontinue treatments due to ineffectiveness, undesirable side effects, or increased tolerability.^1,2 A need for new and effective treatments is evident, with non-pharmaceutical therapies being highly desirable. Cognitive behavioural therapy (CBT) is a non-pharmaceutical, psychological approach that can be integrated into your pain management plan.² Some studies have shown slight improvements in the intensity of chronic pain and its disabling effects.² Read on to find out more about the use of CBT for chronic pain treatment.

Understanding chronic pain

Chronic pain is a complex issue, affecting a huge portion of the global population and 13-50% of people in the UK. Of this population of people, there are around 10-15% with disabling symptoms.³ Pain is described as an unpleasant sensation associated with potential or actual tissue damage, and chronic pain is recognised when it lasts longer than 3 months.¹ The sensation of pain occurs as a result of your central nervous system, where nerve endings in your tissues send signals to your brain that cause you to feel pain, usually to alert you of tissue damage or illness. In many cases, these signals are not actually the result of any real tissue damage but a problem with or damage to the nerve that is sending the signal. 

In the last few decades, researchers have made advances in both the pathology and treatment of chronic pain. The extent of chronic pain, in terms of its intensity and duration, is affected by physical, social, psychological, and emotional factors. Furthermore, your overall well-being and quality of life often decline with the occurrence of chronic pain, so there is a significant need for an effective treatment. There are a variety of treatment options for patients with chronic pain; however, none so far has come without side effects, high tolerances, and complete elimination of pain, which is very rare. There is a specific need for a treatment that is non-invasive and non-pharmaceutical, as existing treatments are often accompanied by harmful limitations.⁴ 

What is cognitive behavioural therapy (CBT)?

Cognitive behavioural therapy (CBT) is a treatment approach that has gained traction and has been extensively researched in recent years.² CBT aims to help retrain your brain so that the thoughts and behaviours you associate with chronic pain are positive or neutral rather than negative, ultimately improving your quality of life.^4,5,6 This type of therapy aims to reduce the effects of chronic pain in conjunction with other treatments. Research shows that when someone with chronic pain has continual negative emotions and behaviours, the intensity of the pain increases and disabling effects are more likely to occur. This effect can continue in a negative cycle that can worsen your condition.^1,2,5

Some studies have reported evidence that CBT can rewire the parts of the brain that are associated with chronic pain.⁴ It can even affect the mechanisms of pain receptors and the production of neurotransmitters involved in pain pathways in the central nervous system (brain and spinal cord), by reducing the sensation of pain before your brain processes it.⁵ Furthermore, some evidence suggests that CBT affects inflammatory factors surrounding the nerves located at the source of pain in your body.⁵ There are a number of techniques used in CBT that make it possible to do this, and these include:⁵

• Exposure therapy
• Relaxation training
• Behavioural activation
• Mindfulness techniques
• Emotion regulation

CBT addresses psychological responses associated with chronic pain. Psychological responses can include:^2,5

• Repetitive negative thoughts
• Negative emotions such as fear, anxiety, depression, or anger
• Behavioural reactions/habits

CBT has been used to reduce pain for many types of conditions, including:⁵

• Chronic neck or back pain
• Chronic pelvic pain
• Chronic abdominal pain
• Rheumatoid arthritis
• Irritable bowel syndrome (IBS)

Application of CBT for chronic pain

CBT is a treatment delivered by a therapist either face-to-face, over the phone, or via video call.² Alternatively, CBT can be self-led using pain management plans delivered via the internet or even a smartphone app. Some studies have revealed that for some people, CBT, particularly therapy self-managed online, can reduce the number of pain-related visits to emergency care and the times they catastrophise their pain when used in conjunction with other pain treatments .^6,7

^{The basis of CBT, when used to treat chronic pain, is to first set goals and plan treatment, then identify and challenge the negative thoughts associated with your chronic pain and use behavioural techniques to change the way you respond.5} 

CBT techniques include:⁸

Shifting focus

Shifting excessive focus from pain to a distraction, recognising irrational thoughts, and focusing on a more positive thought process concerning your chronic pain.

Exposure therapy or graded exposure

This type of therapy involves confronting and eventually completing tasks or activities that are associated with or trigger your chronic pain.^5,8 This kind of therapy can start small and, over time, gradually build up to a larger or increased duration of these tasks or activities.⁸

Relaxation training or mindfulness

This involves breathing techniques, progressive muscle relaxation, and meditation.⁸ 

Behavioural activation

Stop yourself from avoiding specific actions due to the associated pain. Instead, practise these actions in a mirror and spread out repeated activities or tasks that may trigger pain.⁸

Emotional regulation

This involves incorporating practices to actively notice or check in with your emotions related to your chronic pain, particularly fear, anxiety, anger, and depression. Then, techniques suggested by CBT resources or psychologists should be used to regulate these emotions.⁸

CBT will also sometimes focus on modifying lifestyle factors that can affect chronic pain. Some lifestyle factors that are targeted include hygiene, a healthy diet, regular physical activity, an appropriate amount of sleep, and ensuring you have social support.⁵

Practical tips for incorporating CBT into chronic pain management

When you are planning to incorporate CBT into your chronic pain management plan, you should consult your healthcare provider to determine the best approach for your specific situation. They will provide you with the resources required to start self-managed CBT or refer you to a psychologist for CBT therapy sessions.

There are a variety of other treatments used to treat chronic pain that CBT can be used alongside. Some of these include:¹

• Pharmaceutical: analgesics, opioids
• Local anaesthesia: anaesthesia applied directly to the area of pain
• Operative procedures: spinal surgery, joint replacements, abdominal surgeries, etc
• Neuromodulation methods: spinal cord stimulators, implantable drug delivery systems

It is important to build a strong support system that can provide you with emotional, mental, and, if necessary, physical support. This can include your family, friends, or a support group. It can also be important to inform your workplace of your condition to ensure they accommodate you where they can. 

Benefits of CBT compared to other treatments for chronic pain

There are several reasons why you might opt for CBT instead of other treatments to manage your chronic pain. These include:

Accessibility

CBT is easily accessible to patients via phone and video conference with a therapist or using resources for self-led therapy.²

Cost-effective

The cost of CBT is significantly less than both invasive surgeries such as spinal surgeries as well as the ongoing costs of pharmaceutical treatment.⁴

Non-invasive

CBT does not require any type of invasive procedure.

Tolerability

Unlike many drugs used to treat pain, there is no known tolerance developed for psychological therapies like CBT.⁴ 

Non-addictive

 Unlike pain management drugs, such as opiates, CBT has no addictive properties.⁴

Challenges and limitations of CBT for chronic pain

Further research is required to grasp the extent of the challenges and limitations involved with CBT. CBT is less successful when applied to patients with more intense chronic pain. People with this condition will require more frequent or intense CBT than those with lower levels of pain.⁸ Further research is required to determine if CBT is an effective treatment for chronic pain in the long term.⁵ While the psychological factors can be successfully managed using CBT, there is limited evidence that it is helpful for physical causes of chronic pain.

Summary

Chronic pain is a global issue that affects a large percentage of the population in a number of different physical and disease states. Currently, there are many treatments that cater to the physical aspects of chronic pain, including pharmaceutical drugs, surgical interventions, and other procedures. However, there are limited resources that aim to improve the psychological aspects of chronic pain. CBT is not expected to be successful on its own and further research is needed to determine if it is successful as a long-term treatment. Nevertheless, it is still a great tool to use in conjunction with other pain management treatments and is very accessible when delivered online. It is important to seek help from a healthcare professional who will help you obtain the resources you need to start CBT and assist you in incorporating this into your pain management plan.