Cognitive behavioral therapy (CBT) is a type of therapy in which patients identify negative thought patterns and replace them with positive ones. It combines techniques used in behavioral therapy and in cognitive therapy. It is based on the principle that a person’s beliefs about pain can influence adjustment to the pain experience.
Unlike typical forms of psychotherapy, cognitive behavioral therapy focuses on present and future thoughts and behaviors, not past conflicts. CBT is usually short-term, whereas traditional psychotherapy is often long-term.
CBT is used to treat a variety of mental disorders but is also used to treat pain patients, particularly those experiencing chronic pain. Conditions for which CBT is sometimes prescribed include arthritis, back pain, headaches, insomnia, fibromylagia, lupus, chronic fatigue syndrome, sickle cell anemia and some types of chest pain, abdominal pain and pelvic pain.
CBT is sometimes used when patients with pain conditions do not respond to other types of treatment, such as physical therapy or medications. It may also be used in conjunction with such treatments.
Before receiving CBT, patients are asked to describe symptoms to determine whether emotional factors may be playing a role in the pain experienced.
CBT may be conducted in one-on-one or group sessions. Skills that patients may be taught include keeping a diary, pacing activities, relaxation therapy and cognitive therapy.
Potential benefits of CBT include decreased psychological distress, better pain management and improved quality of life.
About cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a type of therapy aimed at identifying negative thought patterns and behaviors and replacing them with positive ones.
CBT is based on the theory that internal thoughts (cognition), rather than outside circumstances, shape behavior so a person’s beliefs about pain can influence adjustments to the pain experience. Distorted thinking thus leads to damaging behavior. Unlike typical psychotherapy, CBT focuses on changing present and future attitudes and behaviors, rather than addressing past conflicts. CBT is usually structured and conducted over short-term periods, whereas other forms of psychotherapy are often conducted over longer periods of time.
CBT combines techniques used in behavioral therapy and cognitive therapy. The focus of behavioral therapy (also called behavior modification) is to replace undesirable behaviors with healthier ones. Techniques used in behavioral therapy include positive reinforcements (technique in which positive behavior is rewarded) and desensitization (technique by which patients confront situations that cause discomfort, fear or anxiety and overcome negative emotions).
Cognitive therapy involves identification of distorted patterns of thinking, which are called maladaptive schema (fundamental core beliefs or assumptions that are part of the perceptual filter used to view the world). These negative patterns are often responsible for maladaptive behaviors (unsuitable or counterproductive behaviors). Patients try to replace these negative patterns with more constructive ones (cognitive restructuring).
Some common patterns of negative thinking include:
Catastrophizing. Anticipating the worst and exaggerating perceived failures and symptoms, especially of chronic pain.
Filtering. Exaggerating the negative aspects of an experience and minimizing the positive ones.
Personalizing. Automatically accepting blame when something bad happens.
Generalizing. Viewing a troublesome event as the beginning of a never-ending cycle.
Polarizing. Viewing situations as all good or all bad, black or white. Not recognizing the middle ground.
The medical community began using CBT in recent years after recognizing that pain is not simply a biological response to unpleasant stimuli. Rather, there are a number of biological, social and psychological factors that interact in complex ways to influence the experience of pain. Factors that can influence a patient’s experience with pain include previous pain experiences, genetics, depression and other mood disorders, pain beliefs and fears, pain threshold, pain tolerance level and coping methods.
In addition, pain patients often experience emotions such as anger, sadness and anxiety, and may respond better to CBT than medication or other types of treatments.
CBT helps relieve pain in some patients by helping them recognize that emotional responses to pain are influenced by thoughts that can be controlled. CBT can give patients more confidence in their ability to manage their symptoms and sometimes reduces the number of visits to healthcare providers.
CBT is sometimes used when patients do not respond to medications or other types of treatment. But it may also be used in conjunction with medication.
Conditions treated with CBT
Cognitive behavioral therapy (CBT) is often used to treat a variety of mental disorders, such as obsessive-compulsive disorder (anxiety disorder characterized by recurrent, unwanted thoughts and/or repetitive behaviors), eating disorders and agoraphobia (fear of open spaces). It is also used to treat a wide variety of pain patients. It is mostly used in combination with other treatments.
When employed in pain management, CBT is most often used with patients who experience chronic pain conditions and who have had minimal or no relief of symptoms with medications. Most patients cannot control severe pain with CBT alone but may use it along with medications or other pain management tools, such as physical therapy, manipulation therapy or biofeedback, to alleviate pain symptoms and reduce emotional distress.
CBT is sometimes a prescribed treatment for conditions including:
Arthritis. Inflammation of the joints. Common types of arthritis include osteoarthritis, rheumatoid arthritis and gout.
Headaches. Patients who experience chronic headaches, such as recurrent migraines, are sometimes treated with CBT.
Back pain. Some cases of back pain are not relieved with medication or surgery. Back pain may also be caused or worsened by emotional stress. People who are under stress experience a tightening of the back muscles.
Fibromyalgia. CBT may help people cope with this chronic disorder characterized by widespread musculoskeletal pain, fatigue and tenderness.
Chronic fatigue syndrome. Cognitive behavioral therapy has been shown to help patients cope with this condition and allow increased activities without triggering increased symptoms, according to the U.S. Centers for Disease Control and Prevention (CDC).
Insomnia. CBT is sometimes prescribed to address the sleeping disorders that can accompany many chronic pain conditions, including restless legs syndrome, fibromyalgia, myofascial pain syndrome, chronic fatigue syndrome, polymyalgia rheumatica, sarcoidosis, Lyme disease and chronic joint pain.
Systemic lupus erythematosus. CBT may address the cognitive dysfunction that can affect people with this autoimmune disorder, according to the Lupus Foundation of America.
Sickle cell anemia. Instruction in coping skills can reduce negative thinking and pain.
Chest pain. CBT has been found to aid some patients with noncardiac chest pain due to causes such as esophageal spasms or asthma. Because the therapy has been shown to decrease blood pressure and hostility, it may also benefit those who have or are at risk of heart disease.
Abdominal pain. Some research has supported CBT in treating chronic conditions such as irritable bowel syndrome and ulcers.
Pelvic pain and sexual pain. A combination of CBT and biofeedback has demonstrated effectiveness in relieving vaginismus (recurrent spasms of vaginal muscles). CBT may also help relieve chronic pelvic pain syndromes such as prostatodynia in men and vulvodynia in women.
Trauma pain. For conditions ranging from serious burns to spinal cord injury, CBT can address depression, body image, stress and other issues.
Cancer pain. Pain in cancer patients can be caused by tumors, complications of cancer treatments (such as radiation) or be unrelated to the disease or treatment. CBT can help patients cope with the symptoms of illness.
Before cognitive behavioral therapy
Before cognitive behavioral therapy (CBT) is recommended, a physician usually takes a medical history and conducts a physical examination.The patient is usually asked to describe pain symptoms in detail to determine whether physical ailments are the sole cause of pain, or whether emotional distress is contributing to it.
A physician may also ask the patient to describe other symptoms being experienced in addition to pain, such as:
Fatigue
Memory problems
Irritable bowel
Muscle tension
Shortness of breath
Palpitations
Irritability
Insomnia
Patients may also be asked to describe:
Activities that have been altered by pain, such as sleep patterns
Social support system, such as family and friends
History of emotional, physical or sexual abuse
Identifying symptoms and circumstances that accompany pain can help a physician distinguish between physical and psychological aspects of pain.
Recent research suggests that a brain imaging technique called functional MRI could help identify which patients are more likely to benefit from CBT, such as those with decreased activity in a region called the subgenual cingulate cortex.
If CBT is recommended, patients will be referred to a therapist (a mental health professional such as a psychiatrist, psychologist or social worker). Prior to beginning therapy, a patient and therapist may meet for a consultation session during which the therapist assesses the patient, determines a course of treatment and discusses treatment goals with the patient.
During and after cognitive behavioral therapy
Cognitive behavioral therapy (CBT) may be conducted in one-on-one sessions between a patient and a mental health practitioner, such as a psychiatrist, psychologist or clinical social worker.
CBT may also be conducted in group sessions, which may include patients experiencing a wide variety of pain symptoms. Sessions typically last between 1.5 to 2 hours and are held over eight to 10 weeks.
CBT programs usually include education, skills acquisition and relapse/maintenance training to help patients retain the information and skills learned.
There are a number of skills that patients may be taught during CBT sessions. These may include:
Keeping a diary. Patients record pain sensations three times a day at the same time. This type of pain assessment rates pain on a scale of 0 to 10, with 0 meaning no pain and 10 meaning the worst pain possible. Patients record physical pain and emotional pain (such as anxiety and anger). A diary helps patients identify negative patterns that may be reversed with CBT.
Pacing activities. Patients identify daily activities that cause pain (e.g., sitting at a computer). They also monitor how long the activity is performed before pain is experienced and how long it takes before pain disappears. Patients time themselves while doing the activity to ensure it is discontinued before pain is experienced. Pacing activities help to relieve pain by reducing muscle fatigue, nerve irritation and frustration.
Relaxation therapy. Techniques to elicit the relaxation response, which is a quieting response that can balance the physical and emotional effects of stress. Patients are sometimes taught breathing and relaxation techniques so they can be used to alleviate pain during stressful and painful diagnostic tests and therapeutic procedures. These techniques reinforce the connection between mind and body and give the patient more control in reacting to difficult procedures.
Cognitive therapy. Techniques to help patients learn negative emotional responses and alter them. Patients keep track of emotional reactions to events, such as driving in traffic. Common reactions may be anger and frustration, which can lead to increased adrenalin, blood pressure, heart rate and pain.
Patients also keep track of internal thoughts that occur during events, such as thinking, “This always happens to me when I want to get somewhere.” Patients identify patterns, assumptions and distortions in thought processes and try to reframe them with healthier ones, such as thinking, “There is not much I can do about the traffic jam, but I can practice my breathing exercises.” The goal of this technique is to learn to respond, and not react, to stressful situations. Other positives include ignoring pain and indicating acceptance of pain.
Patients being treated with CBT are sometimes required to perform activities outside of therapy sessions, such as behavioral homework assignments. During these, patients try out new responses to situations discussed during therapy.
Patients may be treated with CBT over a short period of time, such as a few weeks or months, or may be treated for longer periods of time.
Potential benefits and risks of CBT
Cognitive behavioral therapy (CBT) can have numerous benefits for patients, including:
Decreased psychological distress
Improved pain management
Increased self-efficacy (the belief in one’s capability to organize and execute the sources of action required to manage prospective situations)
Better quality of life and function
Some research has shown that patients treated with CBT have fewer visits to healthcare providers.
Few risks have been associated with CBT. However, some patients treated with CBT experience relapse (returning to a behavior after it had been stopped for a period of time). This occurs because patients tend to forget information or discontinue skills learned over time. Relapse can be treated by follow-up therapy sessions. CBT is cautioned in patients with schizophrenia, bipolar disease or personality disorders because it may initially exacerbate these conditions.
Questions for your doctor about CBT
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about cognitive behavioral therapy:
What is cognitive behavioral therapy, and can it help my pain condition?
Is cognitive behavioral therapy the appropriate type of therapy for me? Do I have conditions that rule it out?
Should I receive cognitive behavioral therapy in a one-on-one session, a group or both?
Do you recommend a particular therapist or facility?
What techniques will I learn during cognitive behavioral therapy?
How often will my sessions take place, and how long does a session last?
How long will I have to go to cognitive behavioral therapy?
What are the benefits and drawbacks of seeking this therapy?
Should I continue to take medication as usual during cognitive behavioral therapy?
Can I also have other treatments during this time, such as physical therapy?
What is the next course of action if cognitive behavioral therapy does not work for me?
