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Behavioral Medicine: How to Incorporate Into Pain Management

‘Cognitive-behavioral interventions improve psychological and physical functioning. They help patients let go of the struggle against pain and move toward achieving their most valued life goals. Medical management is also more effective if depression, anxiety, and other mental health symptoms are addressed.’ —Mark Jensen, PhD
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In CBT, chronic pain syndrome is defined as a constellation of symptoms (mood, relationships, social activities, work/education, play/leisure, etc) that usually do not respond to the biomedical model of care. This condition is best managed with an interdisciplinary approach requiring good integration and knowledge of multiple organ systems.34 Since the 17th century, there have been several different theories of pain perception, from the intensity theory to the gate-control theory of pain. Intensity theory proposed that a stimulus sensation and a reflex response operate within identical neural circuitry, but are differentiated by way of intensity. A stimulus, like an itch, would activate neurons at a low level, while a reflex response, such as soothing from scratching, would generate neurons at higher levels. Evidence against intensity theory has since developed and ultimately led to the current philosophy.

In 1965, the gate control theory proposed that there is a “gate,” or control system, in the dorsal horn of the spinal cord through which all information regarding pain carried by the nerves of the body must pass before reaching the brain. When the gate is “open,” the nerves can carry signals from the body to the brain, where pain is perceived. Chronic pain is believed to persistently activate this transmission to the dorsal horn and induce it to “wind up.” Over time, this phenomenon induces pathological changes that lower the threshold for pain signals to be transmitted. When the gate is “closed,” the nerves signals are restricted access to the brain. The goal of CBT is to help “close” the gate.

CBT protocols also introduce cognitive concepts, such as automatic thinking and cognitive restructuring. Automatic thoughts spontaneously come to mind when a particular situation occurs. Cognitive distortions, unconscious operations of the mind, are categories of automatic thinking. People do not choose their cognitive distortions, but act on them without even being aware of their negative implications. Negative thinking opens the “gate” and causes an increase in pain perception.

The first step to changing cognitive distortions is to recognize them. Negative cognitive distortions fall into 4 broad categories, including overgeneralization (taking isolated cases and using them to make wide generalizations), mental filters (focusing on negative aspects of an event while ignoring positive aspects), jumping to conclusions (making decisions from little evidence), and emotional reasoning (making decisions based on personal feeling rather than evidence).

Cognitive restructuring is a useful tool for understanding and turning around negative thinking. It involves observing negative thoughts closely, challenging them, and re-scripting the negative thinking that lies behind them. By engaging in this active process, the patient learns to approach situations in a positive frame of mind. The key idea behind cognitive restructuring is the A-B-C model, which purports that interpretations of the environment (or activating event-A) affects cognitions (or beliefs about the event-B), which in turn drives our emotions and bodily sensations (or consequences-C).

Furthermore, CBT protocols introduce behavioral strategies, such as relaxation techniques (any method, process, procedure, or activity that helps a person to relax), time-based activity pacing, and pleasant activity scheduling. There are several types of relaxation techniques employed in CBT, including diaphragmatic breathing, progressive muscle relaxation (PMR), and visual imagery. Diaphragmatic breathing is the act of breathing deep into the lungs by flexing the diaphragm, rather than breathing shallowly by flexing the rib cage or raising the shoulders. This deep breathing is marked by expansion of the abdomen rather than the chest when breathing. It is generally considered a healthier and fuller way to ingest oxygen, the source of life, and is often used as a therapy for pain management.

PMR is a technique for reducing muscle tension by alternately tensing and relaxing the muscles. PMR entails physical and mental components. The physical component involves the tensing and relaxing of different muscle groups of the body. With the eyes closed, and in a sequential pattern, tension in a given muscle group is purposefully held for approximately 10 seconds and then released for 20 seconds before continuing with the next muscle group—usually starting with the toes and feet and then going up the body. The mental component focuses on the difference between the feelings of tension and relaxation. Because the eyes are closed, one’s concentration is focused on the sensation of tension and relaxation. In visual imagery, the therapist guides the patient through a process of visualization to create images that serve as messages from the unconscious to consciousness. In order for these images to be effective, the visual imagery exercise should be practiced at least once daily.

Another behavioral strategy that is taught is time-based pacing, or an activity-rest cycle. There are 4 steps to time-based pacing: list some things the patient tends to overdo, limit the amount of time for the activity, stop the activity and rest when the time is completed (not the task), and repeat the cycle until the task is complete.

Pleasant activity scheduling is another way to increase positive emotions and to “close” the gate. There are 4 steps to pleasant activity scheduling:

  • List activities that the patient thinks might be pleasurable
  • Rate each activity according to current ability
  • Schedule the activities during the next week
  • Review progress, then attempt again during the next month

At the end of the intervention, patients create a plan for how to use the skills learned when they have a pain flare-up. The plan involves the following steps: 1) prepare for a flare-up before it occurs; 2) confront the flare-up head-on (do not ignore it); 3) avoid pitfalls during critical moments (watch out for cognitive distortions); and 4) reflect upon which skills were successful and create a new plan for the next flare-up, because there will be another one in the future.

Last updated on: May 12, 2017
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