This article reviews the cognitive-behavioral (CB) perspective on chronic pain and discusses the distinction between this perspective and cognitive and behavioral techniques. We describe the general efficacy of cognitive-behavioral therapy (CBT) in the treatment of people with chronic pain along with some of the limitations of published outcome studies. We discuss advances in moderation and mediation of treatment outcomes. Lastly, we discuss the need for research that takes into account growing interest in evidence-based medicine, methods that address responders and nonresponders, individual trajectories, how we might advance and refine CBT, and strategies related to relapse prevention, maintenance, and adherence enhancement taking advantage of evolving technological methods of service delivery. We provide recommendations on how to approach studies of CBT efficacy as a function of better understanding of patient characteristics and context. We advocate for the potential of the CB perspective for all healthcare providers regardless of discipline or training.
Keywords: cognitive-behavioral therapy; treatment outcomes; chronic pain; responders; maintainance; mechanisms
The perception of pain is one of the most common reasons people seek medical treatment for most physical conditions. It is one of the defining features of many diseases. Chronic pain (i.e., pain lasting beyond the expected period of healing or persisting beyond 3-6 months) is estimated to affect approximately 30% of the adult population in western countries (Tsang et al., 2008) and consequently approximately 100 million adult Americans. In the United States (Institute of Medicine, 2011), the National Center for Health Statistics (2006) estimates that up to 10% of adults reported that they had pain that lasted a year or more, and 40% note that their pain has a moderate or severe degrading impact on the quality of their lives. A World Health Organization (WHO) survey of primary care patients in 15 countries reported that 22% of patients reported pain present for 6 months or longer that required medical attention, medication, or interfered significantly with daily activities (Gureje, Von Korff, Simon, & Gater, 1998). Chronic pain is a common occurrence among children and adolescents as well, affecting up to 25% of children and adolescents (Perquin, Hazebroek-Kampschereur, Hunfeld, Bohnen, Lisette et al., 2000). Cumulative costs including treatment, disability payments, lost work days and tax revenue, and legal fees attributed to chronic pain may exceed $600 billion per year (Institute of Medicine, 2011).
The figures for prevalence and cost cited, however, do not provide an adequate reflection of the impact and incalculable suffering that accompanies persistent pain. For the people experiencing chronic pain, there is a continuing quest for relief that remains elusive as they trek from health provider to health provider and diagnostic test to diagnostic test in search of successful diagnosis and treatment (i.e., eliminated). Patients may develop treatment-related complications or experience "medical limbo" (i.e., the presence of a painful condition that eludes diagnosis and that carries the implication of either psychiatric causation or malingering on the one hand, or an undiagnosed potentially progressive and disabling condition on the other). These complications are in their own right a source of significant stress and can initiate emotional dysfunction. The lives of people with chronic pain are compromised at all levels-emotionally, behaviorally, and interpersonally (i.e., Turk & Okifuji, 2002). Summing up the situation, the presence of persistent pain carries profound physical, emotional, social, and economic burdens not only for the persons experiencing the symptoms but for their significant others and society as well.
In most cases, biomedical factors appear to instigate the initial report of pain. Over time, psychosocial and behavioral factors play an increasing role in maintenance and exacerbation of the level of pain, influence adjustment and adaptation, and contribute to excessive disability. …