Learning Objectives

This is an intermediate level course. Upon completion of the course, mental health professionals will be able to:

• Identify two psychological factors in pain perception.
• Explain the relationship between chronic pain and psychopathology.
• Describe 3 psychological variables impacting stigma related to chronic pain.
• Outline two models for treating chronic pain and PTSD.
• Describe three evidence-based psychological interventions used to treat pain.
• Discuss health provider bias toward pain management in marginalized population.
• Identify two positive and two negative effects of pain on family members.

The materials in this course are based on the most accurate information available to the author at the time of writing. The scientific literature on pain grows daily and new information may emerge that supersedes these course materials.

Outline

• Introduction
• The Normal Psychology of Pain
  • Model of Analgesic Problem Solving
  • The Perception of Pain
  • The Perseverance Loop
  • Mechanisms of Change
  • Transactional Model of Stress and Coping
• Psychological Impacts on Pain
  • Stages of Grief of Pain
  • Fear-Avoidance and Pain Catastrophizing
  • Suicide: Assessment and Prevention
  • Resolving Difficult Behaviors
• Social Aspects of Pain
  • The Role of Family in Pain Management
  • Stigma Attached to Chronic Pain
  • Chronic Pain Management in Marginalized Populations
  • Axes of Privilege
  • Changes to the Diagnostic and Statistical Manual of Mental Disorders-5
• Chronic Pain and Common Psychopathology
  • Depressive Disorders
  • Anxiety Disorders
  • Trauma- and Stressor-Related Disorders
  • Somatic Symptom Disorders
  • Personality Disorders
  • Substance-Use and Addictive Disorders
• Chronic Pain and Other Psychiatric Conditions
  • Schizophrenia Spectrum and Other Psychotic Disorders
  • Sleep-Wake Disorders
  • Bipolar and Related Disorders
  • Neurocognitive Disorders
  • Obsessive-Compulsive and Related Disorders
  • Dissociative Disorders
  • Anger Expression and Disruptive, Impulse Control and Conduct Disorders
• Chronic Pain and Polarizing Topics
• Neurodevelopmental Disorders
• Feeding and Eating Disorders
• Elimination Disorders
• Sexual Dysfunctions
• Gender Dysphoria
• Paraphilic Disorders
• Process or Addictive Disorders
• Evidence-based Psychological Interventions
  • Classification System
  • Sensory Component: Modifying the Emotional and Cognitive Meaning
  • Affective Component: Focusing on Effects that Alleviate Pain
  • Cognitive Component: Making Changes in Patient Attitudes Toward Pain
  • Psychoeducation
    • Cognitive Coping Therapy
    • Second Wave of Psychotherapy
    • Integration of the Third Wave
    • Behavioral Component: Using Learning Processes
    • Models of Behaviorism: Learning Theory
• Pain Interventions in Different Settings
  • How to Utilize Acceptance and Commitment Therapy for Pain in Primary Care
  • How to Deliver Cognitive Behavioral Therapy for Pain in Primary Care
  • Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD
  • Limitations of MBSR
  • Comorbid Chronic Pain and PTSD Using Integrated Cognitive Behavioral Therapy
• Implementation and Dissemination
  • Monitoring Mental Health in Pain Management
  • Relapse, Noncompliance, and Adherence Enhancement
  • Defining the Terms
  • Improving Access to Care Through Choice
  • Revisiting Case Samples
  • The Role of Telemedicine in Pain Management
• References

Introduction

This course provides an exploration of the psychology of pain. It encompasses a combination of articles that were published from 2017-2021 in the Practical Pain Management (PPM) Journal. The PPM Journal provides in-depth clinical information on a variety of pain conditions and treatment approaches, including behavioral medicine. It differs from the other pain course by this author on this website, Pain Relief: Putting Pain Management in Your Client’s Hands. That course is a general review of pain management and serves as a good introduction to this one, which takes a deeper dive into the psychology of pain. This course can be completed on its own or as a follow-up to the other course. Interested readers will find an extensive Additional Reading list at the end of the course.

The Normal Psychology of Pain

Pain is a normal feature of the human experience. Commonplace pain has a particular psychology which provides the foundation for all pain management behavior. A normal psychology of pain seeks to explain the shared experience of pain that is uncomplicated and short-lived. It is straightforward in the sense that it is diagnostically minor (such as headaches) or related to slight trauma that does not require clinical intervention (such as bruises). There are two core aspects beyond the sensory features of normal pain:

• its social or communicative function; and

• its interruption of mental preoccupations or escape/avoidance.

Pain is hard-wired as a social alarm of a threat which is then selected over other competing demands and triggers behaviors that interfere with normal life functioning. Each individual’s experience of pain and its expression is a product of:

• the sensory experience;

• the person’s personal background;

• the interpersonal context; and

• the meaning it has for the individual.

A Model of Analgesic Problem-Solving

In 2007, an exploratory model of analgesic problem-solving was proposed. This model helps to capture how normal pain operates to interrupt attention and promote problem-solving behaviors, which range from impassive and persevering to highly dramatic and panic-stricken.

1. It begins when pain interrupts the person’s attention and forces them into an unwanted and unwelcome focus on their body.

2. The pain is then appraised as a threat and makes them more vigilant to and drives them toward problem-solving behaviors.

Oftentimes, patients are faced with no options, techniques, or methods at their disposal to achieve escape.

3. Whichever solution the person follows will then either be effective or ineffective.
   1. If it is effective, then they return to a pre-interruption state.
   2. If it is ineffective, the person can become static in the perseverance loop. In other words, they may be actively and repeatedly engaged in effortful attempts to solve the wrong problem. These effortful attempts will then fail because:
      • pain falls outside of the individual’s expectations;
      • lasts too long;
      • does not respond to treatment; and
      • impairs their social function.

The Perception of Pain

The experience of pain has been found to have two distinct neural pathways. When a pain signal comes from any part of the body to the brain, the anterior cingulate cortex is activated, which is associated with the perception of pain. However, people react differently to this stimulation because the feeling is determined by the activation of the medial prefrontal cortex and nucleus accumbens, which are associated with motivation and emotion.

Furthermore, there are non-physiological factors that contribute to the perception of pain, including personality, cognitions, beliefs, socio-cultural variables, learning, and emotional reactivity.

Personality. The perception of pain may be determined by the attachment style of the patient, whether anxious or avoidant.

• Individuals with an anxious attachment style crave close and intimate relationships, but tend to sacrifice their needs to keep their partner happy. Individuals with this attachment style tend to feel more pain in the presence of a person who does not empathize with their condition.

• Individuals with an avoidant attachment style tend to value independence and self-sufficiency more than intimacy. Individuals with this attachment style report less pain when alone then when in the presence of another person.

These two attachment styles are related to a wide variety of close relationship processes and outcomes, specifically personality constructs. Over the past few decades, several theories have been proposed about personality in the chronic pain population. With the advent of the biopsychosocial approach in the 1980s, the diathesis-stress model dominates the field. This model accentuates the interplay between an individual’s biological predisposition and the impact of the environment to explain the different responses to chronic pain. Overall, chronic pain patients are characterized by prevailing harm avoidance and lower self-directedness.

Cognitions. The study of cognitive processes underlying all patterns of behavior can be broken down into two categories:

• Form and/or structure
  • The cognitive structures organize and carry out the direction of the pain experience through attention, memory, decision-making, and other self-regulatory processes.
• Contents of thoughts
  • One particular response to pain which may be predictive of its severity is catastrophic thinking. Catastrophic thinking is defined as the response to a pain experience, whether occurring or anticipated, resulting from an overly negative mindset. Current conceptualizations of catastrophic thinking most often describe it in terms of appraisal or a set of maladaptive beliefs. Maladaptive thinking falls into four broad categories, or types of cognitive distortions, including:
    • overgeneralization;
    • mental filter;
    • jumping to conclusions; and
    • emotional reasoning.

Beliefs. There are other principles that have an impact on how much pain patients feel, including:

• Self-efficacy
  • Self-efficacy is a personal judgment by the patient on how well they can execute a course of action required to deal with a prospective situation.
• Locus of control
  • Locus of control is the degree to which a patient believes that they have control over the outcome of events in their lives, as opposed to external forces beyond their control.
• Involvement in the sick role
  • A patient is considered to be involved in the sick role when they adhere to the specifically patterned social role of being sick.
• The placebo/nocebo effect
  • The placebo response occurs when a non-specific treatment proves to be effective as an analgesic when administered by an enthusiastic, credible proponent of its efficacy. If the patient’s beliefs inadvertently increase their anxiety and expectations of pain, it is assumed they have had a nocebo effect.

Sociocultural variables. Early theories of the psychology of pain assessed global factors, such as:

• Gender
  • In most studies, women generally reported experiencing more recurrent, severe, and longer-lasting pain than men
• Age
  • Past research has also shown that pain thresholds increase with age.
• Culture
  • It was once believed that we as human beings differed culturally in some way which affected how we experienced pain. For example, there was a notion in the 19th century that racial groups varied in their physiological experiences to pain which was later found to be unsubstantiated. However, we now understand that there are differences within cultural groups that may affect their pain experience, including generation, acculturation, SES, ties to mother country, primary language, degree of isolation, and residence in ethnic neighborhoods. These factors may mediate the relationship between culture and pain.

Learning. Pain can be a conditioned response, or learned behavior, rather than only a physical problem. The behavior begins purely in response to the presence of an injury, and then it is reinforced and becomes a conditioned response. Pain behaviors, such as guarding, bracing, rubbing, grimacing, and sighing may lead patients to perceive that they have more pain, if reinforced. In a similar fashion, inactivity may relieve pain in some patients, but leads to a vicious cycle of deconditioning and further worsening of pain. Pain can result from these conditioned fear reactions, or avoidance behaviors, that persist even after the resolution of pain.

Emotional reactivity. Relative to other negative emotions, such as fear, sadness, guilt, self-denigration, and shame, anger is the most prominent emotion in chronic pain patients. Anger refers to an emotional experience which can be a current mood state or a general predisposition toward feeling angry. However, the experience of pain may help reduce anger by developing empathy. Empathy is the capacity for a patient to understand or feel what another person is experiencing from within their frame of reference, that is, the capacity to see the world through another person’s eyes. It is the capacity to recognize pain in other people. Research has shown that human beings tend to be more empathic toward their friends and that stress may deter people’s ability to empathize.

The Perseverance Loop

Interventions aimed at enabling patients to break out of the aforementioned perseverance loop and change their perception of pain may be more effective than interventions that appear to endorse the patient’s view of the problem as one that can only be solved by pain relief. Psychotherapy produces long-term changes in behavior through learning, which generates changes in gene expression that alters the anatomical pattern of interconnections between nerve cells of the brain. The regulation of gene expression by psychosocial factors makes all bodily functions, including brain functions, susceptible to psychosocial influences.

Mechanisms of Change

There appears to be a lack of awareness and understanding of the mechanisms of change involved in psychotherapy. There is the physiological process, which includes:

• musculoskeletal activity;

• heart rate;

• blood pressure;

• EEG patterns;

• sympathetic arousal;

• production of endogenous opioids;

• production of neurotransmitters;

• neurohormonal activity; and

• cortical functioning.

Interventions based only on the biomedical approach may appease the patient who is focused on solving their pain by relief.

Another process is creating change through cognitions, which addresses the patient’s:

• covert self-talk;

• thoughts; and

• beliefs.

The focus of treatment in these interventions is to reduce the rigidity of belief in pain as requiring a biomedical approach and in changing the problem frame from one of needing a cure to one of managing a chronic illness.

A third process is via a change in overt behavior, which includes:

• the way one acts; and

• the way one talks.

A behavioral therapeutic treatment may be focused on addressing the anxiety and hypervigilance for signals of possible pain with heightened fear of possible consequences of pain.

A final process is change through addressing emotional reactivity. The focus of treatment may be more of a full accommodation of life, which is changed to one in which pain is a feature and not the center. A transactional coping model can help providers determine which approaches to use in the psychological treatment of chronic pain.

Transactional Model of Stress and Coping

Lazarus and Folkman’s (1984) Transactional Model is one of the most comprehensive theories of stress and coping in the psychological literature, but has received little empirical attention in chronically ill populations. The model assumes that it is a person-situation interaction, or transactional process, when a patient perceives a threat. The threat level is dependent on the initial subjective judgment of the patient, or primary appraisal. A secondary appraisal then occurs, which is a judgment concerning the benefits and consequences of a particular coping style, given the person’s goals and constraints.

• Problem-focused coping refers to coping strategies aimed at solving or changing the problem, such as obtaining information about the pain or seeking medical attention.

• Emotion-focused coping is used to manage or regulate the emotional response to the pain, such as exercising, meditating, or engaging in activity to help forget about the pain.

Then there is a reappraisal, which determines the effectiveness of the coping strategy and the patient’s psychological adjustment. According to this model’s goodness-of-fit hypothesis, problem-focused coping is most appropriate when situations are appraised as changeable, while emotion-focused coping is most ideal when situations are less changeable. If the wrong approach is used, the stress remains unresolved and creates its own perseverance loop (Cosio, 2022a).

Psychological Impacts on Pain

Stages of Grief of Pain

All human beings have three common experiences, namely life, death, and grief. However, despite grief being a universal experience that everyone will face in some form during their lifetime, the literature dealing with this critical topic is conspicuously scarce. Loss related to grief is not just about death, but can include a number of situations, including loss caused by chronic pain. The fear of being incapacitated due to pain for some patients may be similar to the fear of death. In fact, when a person suffers the loss of a loved one, it feels like losing a part of oneself. In addition, past literature has described the reactions to loss due to death as being similar to other forms of loss, including chronic pain and illness.

Patients with chronic pain experience considerable losses as a result of the multiple impacts it has on different aspects of their lives. Earlier research has found that patients suffering from chronic pain experience a loss in their ability to engage in meaningful activities, in relations with others, and of self. More specifically, research has found subthemes, including loss of abilities and roles, employment-related losses, financial and related losses, relationship losses, and loss of identity and hope. Other themes have been reported, including not being understood by those around them and feeling changed as a person. These losses, in turn, potentially change how these individuals perceive the world.

What Is the Normal Grieving Process? There is no single way to grieve and no single definition of “normal” grief. It is normal for people to experience a range of intense emotions, negative cognitions, and altered behaviors for a period of time after the loss. The most widely cited framework, the Kubler-Ross model, is popularly known as the “Five Stages of Grief.” The five stages include:

1. Denial
   • During stage one, denial and shock help a person to cope and make survival possible. But as the individual proceeds, all the feelings they were denying begin to surface, such as anger.
2. Anger
   • During the second stage, there are many other emotions underneath, such as guilt. But anger is the emotion people are most used to managing.
3. Bargaining
   • Guilt is often bargaining’s companion during stage three. Folks want life returned to what it was or want to go back in time.
4. Depression
   • After bargaining, their attention moves squarely into the present. The fourth stage, depression, feels as though it will last forever, but it is a necessary step along the way to healing, or acceptance.
5. Acceptance
• Acceptance, the final stage, is often confused with the notion that people must accept needless suffering. However, acceptance does mean having to accept living with a certain amount of pain. Acceptance does not mean that a person has to give up all hope and feel defeated. Rather, people can maintain hope for a better future while accepting today’s unpleasant realities. Acceptance does not mean that they have to accept someone else’s version of their condition (e.g., being given a bleak prognosis and later proving the doctor wrong). Acceptance does not mean "not caring." Healthy acceptance means recognizing that no amount of agonizing over and bemoaning fate is going to make things any better. True acceptance means coming to terms mentally and emotionally with the unpleasant reality. This stage is about accepting the new reality as the permanent reality. In fact, this concept is supported by research which has shown that there are two key factors in the grieving process: “relearning the world” and “adaptation.” People can begin to live again, but they cannot do so until they have given grief its time.

This framework has been criticized by others because it seemingly follows a sequential process or it is believed that the stages last only weeks or months. People forget that the stages are responses to feelings that can last for minutes or hours. Individuals tend to go in one stage and out of another and then may be back to a former stage. They do not enter and leave each individual stage in a linear fashion. This more accurately describes the experience of patients with a chronic illness, such as persistent pain.

What Can Providers Do to Help? Past research has shown that loss and grief related to chronic pain may be less obvious to health care workers working in pain clinics. This may be because grief resembles chronic pain. Frontline practitioners should start by:

1. Asking about and acknowledging the losses experienced

• The primary step in helping patients is to talk with them about their losses. Talking about these losses may help explain the patient’s circumstances. However, oftentimes providers are unsure how to speak to their patient about their loss. Providers must address their own anxieties about loss first. This way, they will be in a much stronger position to respond well to their patient, the person most directly affected. If providers avoid their patient’s grief because they don’t know what to say, this avoidance serves only the provider’s needs. Remember that the isolation the patient feels is almost as painful as the shock and the sadness of the loss itself. It’s ok for providers to admit that they don’t know what to say. Often, the best thing to say is “I’m so sorry you’re going through this. I just wanted you to know I care and am here with you.” As part of their in-depth interviews, patients should be invited to “tell their story.” Providers need to listen to their story without interrupting. They can sit with their patient side by side, so they don’t feel quite so alone. That only requires intention, a willingness to feel awkward, and an open heart.

2. Assessing their needs

• The various types of grief often follow loss or change. Frequently, people are somewhere along the continuum of grief, which starts with normal sadness and moves into normal grief. If the grief persists beyond 6-12 months and is associated with other cognitive, emotional, and behavioral symptoms, then it is considered complicated grief. Complications are evident when the manifestations of grief are absent, are of extreme intensity, are prolonged, develop into a prolonged major depression, or become distorted in some manner.
• Some people experience a persistent inability to overcome their grief for the loss of a loved one for at least one year or more, with intense yearning or preoccupation with thoughts or memories of the deceased person almost every day since the death. These symptoms are severe enough to impair day-to-day functioning and exceeds what is expected based on standards related to the individual’s social, cultural, or religious background. Those with intense and impairing grief after one year may be considered for the new diagnosis of prolonged grief disorder in the DSM-5-TR (APA, 2022).

3. Connecting them with resources

• Frontline practitioners should inquire about a patient’s support system and suggest ways to build that support, such as with friends, family, a support group, a spiritual leader, or in a psychotherapeutic setting. Support groups give people who are grieving another opportunity for empathy, a sense that they are not alone, and an opportunity for learning new insights and coping skills.
  • The American Chronic Pain Association (ACPA) offers a wonderful opportunity for patients with chronic pain to connect with a support group in their area, or will help the patient develop a group. The goal of an ACPA group is to provide support, validation, and education in basic pain management and life skills. Inquiring about a patient’s spiritual beliefs can help providers identify the role such principles play in their lives, whether it be religion, nature, art, or traditional healers. In terms of psychotherapy, the goal of grief treatment should be to learn to live with the loss related to their pain. Learning coping skills to manage the pain can help rebuild self-esteem and relationships.
    • Acceptance and commitment therapy (ACT) can help patients find a way to live a fuller life despite their pain.
    • Cognitive behavioral therapy (CBT) can help with restructuring negative thoughts and unhealthy behaviors to become more adaptive. Past research has shown that grief therapy has been effective in reducing pain and depression, usage of psychotropic medications, and visits to psychological health care providers.
    • Frontline practitioners may want to also consider complementary and integrative health (CIH) approaches. Various CIH therapies may be helpful in easing a patient’s transition through grief.
    • Movement programs, such as yoga and massage, can help ease stress and promote relaxation.
    • Recreational activities, such as art and music, can help a patient transform feelings and emotions related to their losses (Cosio, 2019a).

Fear-Avoidance and Pain Catastrophizing

Psychosocial factors have become increasingly recognized as important moderators and determinants of the pain experience. There are a number of variables that tap into a negative pain schema, including pain anxiety, helplessness, and fear. These factors share significant variance with broader negative affect constructs, such as depression.

Fear is the emotional reaction to a specific, identifiable, and immediate threat, such as an injury. Fear may protect an individual from imminent danger as it prompts the defensive behavior that is associated with the fight or flight response. Fear may lead to the avoidance of activities that people with chronic pain associate with the occurrence or exacerbation of pain. Confrontation and avoidance are two extreme responses to this fear, of which the former leads to the reduction of fear over time. Whereas avoidance can be adaptive in the acute phase, the use of continued avoidance during the chronic phase may lead to distress, disability, absenteeism, and increased healthcare costs down the line.

What is the Fear-Avoidance Model? The fear-avoidance model describes how individuals develop chronic, musculoskeletal pain as a result of avoidant behavior based on fear. The model states that:

• negative appraisals about pain and its consequences, including catastrophic thoughts, may result in feelings of pain-related fear, avoidance of daily activities, and body hypervigilance;

• as a result of this misinterpretation, the individual repeatedly avoids the pain-inducing activity and is likely to overestimate any future pain from such activity;

• in turn, the avoidance response ultimately results in physical deconditioning, depression, disability from work, and an inability to participate in recreation or family activities. This cycle perpetuates the pain experience as opposed to moving toward recovery:
  • once the avoidant behavior stops being reinforced, the individual exits the positive feedback loop; and
  • in contrast, if an individual continues his or her independence without negatively thinking about pain, this response style in most cases leads them to accept that they have pain, which is meant to ultimately move them toward a faster recovery.

There is clear evidence that fear avoidance is closely related to increased pain, physical disability, and long-term sick leave in patients living with chronic pain. However, there is still considerable debate over the fear-avoidance model among researchers. While it is argued that the model may be too simplistic for every situation involving fear, discomfort, and chronic pain, it is generally acknowledged among the medical community as a means of diagnosing and understanding how humans positively and negatively react to fear.

Therefore, the question remains – if fear drives disability, then could severe disabling pain make one fearful? It is a classic “chicken or egg” conundrum to determine the direction of causation between fear and disability due to pain.

Catastrophic Thinking. While previous research has focused on an array of coping responses, such as ignoring sensations and diverting attention, the greatest scrutiny has been directed at catastrophic thinking defined as “an exaggerated negative mental set brought to bear during actual or anticipated pain experiences.” Negative appraisals about pain may lead to catastrophic thinking, which then contributes to feelings of pain-related fear.

Catastrophic thinking has been further defined using a three-factor construct that has been replicated in several studies:

• rumination: a relative inability to inhibit pain-related thoughts in anticipation of, during, or following a painful encounter (e.g., “I can’t stop thinking about how much it hurts”);

• magnification: the tendency to magnify the threat of pain (e.g., “I’m afraid that something serious might happen”); and

• helplessness: feeling helpless in the context of pain (e.g., “There is nothing I can do to reduce the intensity of the pain”).

Current conceptualizations of catastrophic thinking describe the process in terms of appraisal or a set of maladaptive beliefs. Maladaptive thinking falls into four categories with many individual variations within each:

• overgeneralization: taking isolated cases and using them to make generalizations (e.g., “If one treatment does not help, then no treatment will help”);

• mental filter: focusing almost exclusively on specific negative or upsetting aspects of an event while ignoring positive aspects (e.g., catastrophic thinking; “I’m feeling better after my treatment and the staff was so kind, but the doctor was so rude.”);

• jumping to conclusions: drawing negative conclusions from little to no evidence (e.g., mind-reading/fortune-telling; “The doctor must think I’m lying because he is asking me more questions than usual”); and

• emotional reasoning: making decisions and arguments based on intuition rather than an objective rationale (e.g., “My doctor simply doesn’t care”).

Measuring Fear-Avoidance. There is no exact prevalence of clinical fear of pain because establishing a cut-off point is difficult. However, fear-avoidance beliefs may be assessed using several different questionnaires, including:

• the Pain Anxiety Symptom Scale (PASS) – Measures fear and anxiety responses to pain related to exaggerated pain behaviors. Associations have been made between PASS and catastrophic thinking;

• the Fear-Avoidance Components Scale (FACS) – Measures pain-related fear-avoidance with a specific pain catastrophic thinking component;

• the Fear-Avoidance Beliefs Questionnaire (FABQ) – Has been used to show that fear-avoidance beliefs about physical activities are strongly related to work loss;

• the Tampa Scale of Kinesiophobia (TSK) – Assesses dysfunctional beliefs about physical abilities; and

• the Photograph Series of Daily Activities (PHODA) – Was recently developed to determine the perceived harmfulness of daily activities in patients with chronic low back pain and to construct a hierarchy of feared movements.

Assessment of pain-related fear is recommended because treatment may only be appropriate for patients who are more likely to be avoiders.

Treating Fear Avoidance. Reality-based education about a patient’s diagnosis and prognosis may help prevent distorted and catastrophic views of health outcomes. It has been shown that employing an interdisciplinary approach based on the biopsychosocial model is beneficial. In terms of psychotherapy, graded exposure to activities can help overcome pain-related fears and negative fear-avoidance beliefs. The basic idea is to gradually expose oneself to the feared situation in a way that allows one to control their fear at each step.

Cognitive behavioral therapy (CBT) and mindfulness-based interventions have been associated with significantly greater improvements in maladaptive coping responses to pain than controls. Acceptance and commitment therapy (ACT) works to help patients find a way to live a fuller life despite their pain. Overall, research has shown that using mindfulness-based therapies for chronic headaches showed significantly greater improvements in maladaptive thinking. In another study, mindfulness-based interventions were effective for improving maladaptive thinking about pain in those with a history of recurrent depression associated with rheumatoid arthritis. (Zautra, et al., 2008)

Other mind-body approaches, such as guided visualization, meditation, and yoga may be effective adjuncts to treating fear-avoidance:

• Guided visualization guides the patient through a process of imagining pictures that serve as messages from the unconscious to consciousness, practiced at least once daily;

• Meditation is a devotional exercise of, or leading to, contemplation. Practicing short meditation exercises has been shown to improve pain and reduce anxiety, depression, and poor sleep; and

• Yoga has been shown to help with conditions such as arthritis, back and neck pain, and headaches. It has also shown to be beneficial in improving sleep, strength, balance, circulation, flexibility, and overall well-being. There has been promising evidence to support the use of yoga and other movement-based exercises for noncancer-related pain conditions, such as low back pain.

Clinicians may also consider recommending to their patients similar holistic techniques, such as using positive self-affirmations, reinterpreting pain, hopefulness and praying, and increasing behavioral activities and exercise.

Avoiding Discussions about Fear Avoidance. Fear-avoidance is a sensitive issue which challenges both pain-management practitioners and patients who suffer from chronic pain. There can be pushback from patients with chronic pain when providing education about the psychological aspects of chronic pain. This resistance typically occurs due to the continued stigma in the general public that believes pain is only a physical sensation, despite years of research that provides evidence to the contrary. Furthermore, individuals who suffer from chronic pain are often concerned about being judged and the potential risk that comes with opening themselves up to these psychological concepts. This resistance reinforces any unwillingness of healthcare providers to provide education. To confront this challenge, providers may benefit from improving their communication skills with compassion and sensitivity (Cosio, 2019b).

Suicide: Assessment and Prevention

A common experience during depression and pain is to have suicidal thoughts. About 10% to 50% of people with pain have suicidal ideations. Over 30,000 suicides occur each year in this country, and it is now the 10th leading cause of death for all ages in the U.S. Thus, screening for suicide among people who suffer from pain is important and can lead to a referral to a mental health professional for treatment if needed. There are several risk factors for suicide:

• Acute and chronic pain;

• Sex and age;

• Previous attempt/plan;

• Depression, hopelessness, and other mental illness;

• Substance abuse;

• Medical issues;

• Financial difficulty;

• Rational thought loss; and

• Relationship problems.

There are also some warning signs to look out for among people with chronic pain, including:

• Talking about wanting to hurt or kill oneself;

• Trying to get pills, guns, or other ways to harm oneself;

• Talking or writing about death, dying or suicide;

• Rage, uncontrolled anger, seeking revenge;

• Acting in a reckless or risky way;

• Feeling trapped, like there is no way out; and

• Saying or feeling there’s no reason for living.

The most important thing to do when someone is having suicidal thoughts is to make sure they are safe. I typically make sure when I am working with someone who has suicidal thoughts that they have a safety plan in place. I also make sure that they have information about the National Suicide Hotline (1-800-273-8255). I encourage them to make sure to seek professional help if they have been considering mental health services already. If not, I may recommend that they call 9-1-1 for police assistance or have someone take them to the local emergency room as a walk-in (Cosio, 2018a).

If the individual is not at any risk of hurting themselves, I will recommend they engage in some healthy coping strategies, such as:

• Stay away from drugs and alcohol;

• Take a nap;

• Take a walk;

• Talk to friends;

• Try relaxation exercises;

• Use distraction;

• Writing/reading;

• Coloring in adult coloring books; and

• “Do whatever works for you!”

Resolving Difficult Behaviors

People who suffer from pain at times are deemed difficult, and providers can also present with common failures. It is important to remember that there are no difficult people, just people with difficulties! So why are people deemed difficult? There are several different reasons, including that they have:

• been mistreated, robbed, or ignored;

• personality conflicts;

• social or financial problems;

• lack of trust, information, or communication;

• cultural differences/language barriers;

• cognitive impairment;

• severe mental health/addiction concerns;

• secondary gain;

• system concerns; and

• negative drug interaction.

Dealing with Specific Personality Types. There are several steps providers can take to deal with specific personality types. The key is to find something likeable about the patient. Here are a few examples of patient types and ways to address them:

• Passive, dependent, demanding patient – Explain limits in an empathic, positive, and clear manner;

• Dramatic, seductive, affectionate patient – Maintain clear, professional limits respectfully;

• Idealizing, easily disappointed patient – Do not make promises, stop setting up disappointment, and do not make comments about other providers;

• Long-suffering, masochistic, denying patient – Validate their suffering;

• Orderly, controlled patient – Take time to answer questions. They’re coping the best they can;

• Somaticizing and hypochondriacal patient – Set regular visits but control overuse;

• Angry, demanding, complaining patient – Allow to express anger/offer input into decisions; and

• Cold-deceitful patient – Avoid arguments/stop interaction/share medical reasoning when saying “no.”

Common Provider Failures. Providers also have common failures. They use jargon and avoid certain topics. They can offer too much information and assume the other person is understanding them. They forget that their patients may be afraid to assert themselves. They at times make jokes and ignore or are unaware of how this impacts the other person. Providers may fail to explain that they work at a teaching hospital or the function of their clinic. Providers are also made to feel like a police officer, judge, or deal-maker which they did not receive training for or wished to engage in.

Boundary Setting. It is apparent that pain management, in particular, requires appropriate boundary setting. This is crucial regardless of the treatment plan, in part because people often find it hard to identify potential disagreements in their relationships. Boundaries are simply rules or limits that individuals create to identify reasonable, safe, and permissible ways for others to behave around them, and to determine how they’ll respond when someone oversteps these boundaries. Establishing appropriate boundaries is a skill that requires a lot of thought and practice.

Instilling Hope. The instillation of hope offers a path back to a sense of possibility in our lives when almost all seems lost. It’s a chance to look forward and wonder what might be over the horizon. Hope gives you strength and fuel to keep putting one foot in front of the other. Sometimes instilling hope is about looking backwards (Cosio, 2018a).

Social Aspects of Pain

The Role of Family in Pain Management

There are more than 100 million people currently suffering from chronic pain, but that statistic does not consider the far reach of pain beyond the sufferer. More specifically, about 43% of households have at least one family member with chronic pain. The effects of chronic pain are not independent to the person suffering from pain, but also reach their family, caregivers, and/or significant others. It can demoralize and depress both patient and family, especially when there is no effective pain control and no hope for relief. Family is the universal institution where basic relationships exist and is the first reference group that shapes an individual’s world. Conversely, there is an equally profound effect of family responses on their loved one’s pain.

Family dynamics can contribute to either the exacerbation of or the recovery from pain. There are two dimensions of chronic pain:

1. There is the loved one whose pain does not show, has fluctuating activity levels, unpredictable mood swings, lack of interest, lost their support, and is isolating; and

2. Then there is the family who is unable to see or feel the pain, take on more responsibility, have added stress, withdraw plans and hopes, deal with emotional outbursts, and are also alienated. Family members may also feel powerless and guilty because they are not able to help more, anxious about financial problems, experience significant lifestyle changes, spend time taking their loved one to medical appointments, and feel stressed due to lawsuits and disability evaluations.

Thus, it is important for frontline practitioners to not only consider the person who is suffering in front of them, but the people directly standing behind them as they too may need support and education about pain management.

Negative Effects of Pain. Chronic pain can negatively impact the family system, which has significant consequences. Chronic pain intrudes on every aspect of family life. There may be loss of sexual expression and intimacy in couples which may lead to separation and divorce. There may be social isolation, which then perpetuates further involvement with the health care system. Family members may experience changes in their thoughts and feelings and exhibit evidence of depression or anxiety. They may engage in ongoing unexpressed family conflict or childhood family issues. Sometimes family members will begin to believe their loved one is attention seeking or avoiding their responsibilities, which will negatively impact their relationships.

Role reversals may emerge between the pain sufferer and other family members. Family members may have added employment responsibilities, but there are other roles that one should consider may have changed. The struggle to recover lost functions and roles can be debilitating to the family, increasing stress, grief, and depression.

Positive Effects of Pain. Chronic pain can also impact the family system with significant positive outcomes, although this is less common. For example, if a spouse was controlling before they developed a chronic pain condition, then the other family members may now have more freedom. Family members may feel good about helping a loved one if they have a strong need to help others. A decrease in intimacy may feel positive to the person who experiences intimacy, or even sex, with their loved one as unwanted. Some members of the household may get additional support or sympathy from other family members. These positive outcomes can lead to family members unintentionally trying to get the patient to maintain the sick role.

Reinforcement of Pain Behaviors. The presence of a well-caregiver can contribute to enhanced cohesion and resilience as the family works together to adapt to the demands of chronic pain. However, the family may also be responsible, in part, for maintaining and perpetuating pain behaviors. Those who surround the person manifesting pain behavior will be required to respond to them. Their mere presence may come to serve as a cue for increased reports of pain. Reinforcement of maladaptive behavior may occur when family members unintentionally provide attention or react caringly to pain complaints. This can best be seen in situations where the person in pain has an over-protective partner or spouse. Remember, attention is a form of love expression but can also be used as a reinforcement.

Family members may also promote fear of harm. They often mean well but begin taking over tasks and even speaking for their loved one. The family member may perform tasks for the loved one in order to terminate the stressful impact of their pain complaints. Family members may also take on more responsibilities which may detract from their loved one’s independence and self-efficacy. Remember, it is important for the person suffering from pain to maintain their independence and that family members support their attempts to return to work. Some families also deal with emotional problems at a somatic level. In other words, they exhibit their emotional problems with physical complaints. The opposite is also true. Some people who suffer from pain live alone, have no family nearby, or have no support system in place. They often feel ignored or express frustration because they do not have anyone to talk to about their problems.

Assessment of Family Functioning. If the family can be involved in maintaining the pain, then they should be also included in the assessment and treatment of pain. Several self-report instruments have been developed to measure family functioning which can be used with families of patients who suffer from chronic pain, including:

• the Family Adaptability and Cohesion Evaluation Scales (FACES II);

• the Family Environment Scale (FES); and

• the McMaster Family Assessment Device (FAD).

There are also observational measures that can be used to assess family interactions, including:

• the Revealed Differences technique;

• the Simulated Family Activity Measurement (SIMFAM) technique; and

• the Manual Interaction Coding System (MICS).

There are assessment processes that have been established specifically for chronic pain. More specifically, the practitioner must first obtain a family history of pain. In addition, information about familial interactions preceding exacerbations, the meaning ascribed to the pain, and the familial casual attributions are important to decipher. Self-report measures can be used to gather some of this information, such as:

• the Spouse’s Perception of Disease (SPOD) questionnaire;

• the West Haven Yale Multidimensional Pain Inventory (WHYMPI); and

• the use of a spouse diary to relate pain to spouse behaviors.

Family members should also be comfortable asking for family or couples counseling if needed.

Family and Couples Counseling. Addressing emotions with support groups, family therapy, or individual therapy can strengthen the family and the individual, as well as reduce the suffering of all involved. Research has shown that discussion groups for patients with chronic pain and their family members help improve communication, support mutual relationships, and better the ability to cope with the pain. However, studies of randomized controlled trials indicate that family-oriented psychotherapies used to treat chronic illnesses generally have small effects, but more research is required for a firm conclusion. There are a number of treatment approaches involving family members that have been developed, including:

• Operant behavioral treatment is based on the operant conditioning model of chronic pain, which proposes that pain behaviors are influenced by social responses of family members. These interventions have been shown to be effective when combined with family support and education about coping skills;

• Cognitive behavioral therapy (CBT) is based on the cognitive behavioral transactional model. Empirical support for the effectiveness of CBT with spouses of chronic pain sufferers exists;

• Structural family therapy proposes that the family system structures, such as enmeshment, rigidity or roles and rules, poor communication, lack of conflict resolution, withholding feelings, and avoiding emotionally laden topics, contribute to the development and perpetuation of pain through maintenance of family homeostasis. Therefore, treatment concentrates on changing the structure of the family so a new homeostasis can be reached without the patient taking on the sick role;

• Family-oriented therapies based on cognitive theory may focus on self-disclosure in the marriage and an increase of the couple’s closeness and intimacy. The couple is encouraged to share appraisals and their thoughts about each other and to openly express negative emotions; and

• Family-oriented therapies based on a strategic perspective consists of interventions that are practical and problem oriented and may include a comprehensive assessment. However, providers must keep in mind that these family-oriented therapies have scant research support for their effectiveness.

Family and Caregiver Self-Care. Members of the family must deal with their own pain and stress resulting from these circumstances. First and foremost, caregivers will want to make sure they maintain a healthy lifestyle, including a healthy diet, exercise and movement, relaxation, and proper sleep hygiene. These will not only help the caregiver face the difficult times ahead, but may also serve as a model to their loved one. Caregivers must stay away from coddling or being punitive toward their family member suffering from pain. Remember, one of the goals of pain management is independence so caregivers should take a more facilitative stance.

Family members must also recognize and overcome the special obstacles that may occur when communicating with persons suffering from chronic pain. Family members will want to learn as much as they can about their loved one’s condition and about treatment options. However, family members need to keep in mind that when communicating with their loved one’s doctors, they must first have their loved one’s permission and consider HIPAA regulations. Family members must always allow the person in pain to directly speak to the doctor and only provide additional information when asked. Family members can add insight into their loved one’s pain by sharing their perception of the pain using a pain score (0-10), describing the pain as it unfolds throughout the day, and helping their loved one complete a pain log or diary. They can also inquire further about the side effects and dosages of medications and/or the appropriate activity levels and limitations. This is best done by taking an approach to pain as “our fight” not “their fight.” Be careful not to take the behavior of a loved one personally. Caregivers need to find others to help care for their loved one and look for support wherever they can find it. Families and support systems work best when everyone is operating at their best (Cosio, 2019c).

Stigma Attached to Chronic Pain

There is substantial evidence that individuals with chronic pain commonly experience stigmatization by others. In fact, the Institute of Medicine 2011 report, Relieving Pain in America, included the oral testimonies of more than 2,000 patients, family members, and caregivers which described the stigma experienced by nearly every patient with chronic pain. The research literature suggests that there are particular pain groups who receive even more stigmatization, including patients with:

• chronic facial pain;

• fibromyalgia;

• chronic fatigue syndrome;

• whiplash;

• nonspecific low back pain;

• rheumatoid arthritis; and

• somatoform disorder.

Stigmatization can be traced back to biblical times in Judeo-Christian societies. For example, in Genesis 4:15, it is said "And the Lord set a mark upon Cain." The term "stigma" derives from the ancient Greek practice of cutting or burning marks on the skin of slaves, criminals, and traitors who were to be avoided. Over the centuries, diverse personal characteristics such as the lesions of leprosy, the behavior of people with mental illness, and the color of skin, acquired a stigmatic status at particular times and societies. In the modern day, stigma is an attribute that is deeply discrediting given a particular set of circumstances and relationships.

Stigma is a deviance from the expected behavior in medical and broader social settings. Providers and the general population are less inclined to help, feel less sympathy, dislike and are distrustful of, people with chronic pain with no clear biomedical explanation. Conversely, patients with chronic pain report that they do not feel believed by romantic partners, relatives, friends, and their healthcare providers.

Stigma is first an external phenomenon in that it is a judgment from others who see them as having a distinct, undesirable characteristic. People who suffer from chronic pain may report discrimination and may also endorse stigmatizing others using statements that express alienation.

The internal stigmatization found in people with chronic pain is similar to that in people with severe mental illness. These and other processes must be better understood in order to understand and buffer the adverse effects of stigma on patients with chronic pain.

Stigma Deconstructed. Stigma is predominately explored through a socio-cognitive framework. As a result, stigma is malleable and changes over time and place. Further, several definitions of stigma have been used in the literature. The following is an integration of several important qualities of stigma:

1. There exists a social identity quality that varies from the dominant culture and is identified by the dominant culture as a salient difference

2. The label then becomes informed by stereotypes creating “us and them” in-groups and out-groups

3. The salient difference is devalued by the dominant group

4. Past researchers emphasize discrimination. This requires power differences (e.g., social, economic, and political) which are often accompanied by individual discrimination and structural discrimination. Importantly, internalized discrimination that operates through the stigmatized person’s beliefs and behaviors often results. Related, a sociologist, Erving Goffman (1963), unpacked the “two faces” of stigma which ask, “Is stigma a personal attribute or social label?” When stigma is seen as a label or stereotype by others, it belongs to the labeler not the target of the label. Therefore, the bulk of the work needed to destigmatize chronic pain conditions and address its adverse consequences lies with the labeler, not the individual with chronic pain.

While the labeler is initially responsible for the impact of stigma, patients with chronic pain often internalize stigma directed at them. Goffman (1963) further reports on the self-fulfilling prophecy potential, in that those with power can alter the self-image of the target. An investigation into internalized stigma and its impact on 92 patients who suffer from chronic pain found that 38% reported internalized stigma. Furthermore, they found that internalized stigma negatively correlated with self-esteem and pain self-efficacy after controlling for depression. Internalized stigma was also associated with cognitive functioning in relation to pain, and resulted in a greater tendency to catastrophize and a reduced sense of personal control over pain.

Cultural and Social Norms. The cultural and social norms of the U.S. include the expectation for objective evidence of a specific cause if a pain condition exists, and improvement when treated with the traditional methods used in the Western healthcare system. These norms have been shown to expand beyond the dominant culture. For example, when a group of Mexican-American women with chronic pain were asked to describe stigmatizing experiences, they found that these norms created suspicion and subsequent stigma on the part of the family, workforce, and others who suffer from pain.

Stigma matters most to people with chronic pain in clinical settings, which may lead to underassessment and underestimation of pain by the healthcare system. The beliefs of patients and health professionals may be diametrically opposed – patients seeking biomedical explanations and providers offering psychosocial interventions. Providers may discount a patient’s self-report of pain, be skeptical and distrust the reality and the extent of the patient’s suffering, and may over psychopathologize the pain which can lead to undertreatment. Other barriers rooted in the current healthcare system may include unmanageable workloads, compassion fatigue, and/or negative empathy. Negative empathy is defined as a decline of empathy that occurs during medical and other healthcare education.

Physicians tend to be viewed in Western culture as aggressive, intelligent, free-of-error scientists battling disease who are lone decision makers. These views privilege providers and reinforce a power hierarchy in the relationship between practitioners and patients. As a result, patients with chronic pain may not advocate for their needs, thinking that providers believe their reported pain is exaggerated and/or imagined, and that they are responsible for their chronic pain themselves and misleading the provider. Further, narrative accounts of people with chronic back pain found that themes of stigma were related to encounters with healthcare, social security and other legal systems, and with physical, psychological, and social loss.

One way to measure perceived stigma and associated factors is by using the Chronic Pain Stigma Scale (CPSS). The CPSS is a 30-item Likert-type instrument that measures stigma from the general public, physicians, and family and across several dimensions of stigma (estrangement, attribution to psychological cause, malingering, bias against opioid analgesics, and general negative attitudes). Higher values of total scores indicate greater perceived stigmatization.

What Variables Impact Stigma? There are several underlying mechanisms for the stigmatizing responses of others. One study found that patients displaying protective pain behaviors were viewed as less likeable than others displaying other types of pain behaviors. Others may be prejudiced and feel less empathy and altruistic motivation toward members of social out-groups than of in-groups. Another contributor to stigma may be the extent to which the person with chronic pain is judged to be personally responsible for their plight, or the attribution of causality. Healthcare providers often feel uncertain or unprepared to manage patients with chronic pain.

Stigmatization is commonly associated with depression. Being stigmatized is associated with decreased self-esteem, strained interpersonal relations, and lowered quality of life. The reason may be that stigmatizing reactions from others challenge maintenance of their sense of self-esteem and dignity.

Ways to Reduce Stigma. Past research describes different levels of intervention to address stigma, including:

• Intrapersonal – Teaching people with chronic pain how to deal with stigma. Self-management strategies emphasize active participation in the multiple personal and social tasks involved in long-term conditions. However, self-management alone may be a counterproductive pursuit for many people with chronic pain. Patients may make every effort to acquire and comply with medical advice but these efforts may not be met with the support or autonomy they desire or expect. Cognitive behavioral therapy (CBT) has been found to reduce anxiety and pain-related disability, but has not been found to reduce perceived stigma. Acceptance and commitment therapy (ACT) may prove to be beneficial as it aims to enable the patient’s ability to adapt to fluctuating situational demands, reconfigure mental resources, shift their perspective, and balance competing desires, needs, and life domains.

• Interpersonal – Creating environments in order to respond in a less prejudiced manner. Health coaching for both the patient and the provider aims to increase the effective management of the medical encounter. An important aspect of interpersonal intervention includes finding a way for the patient to explain their pain to others and to set appropriate boundaries. From a provider perspective, something as simple as acknowledging that a patient’s condition has a name and is a legitimate illness is immensely reassuring and empowering.

• Structural – Can take the form of changes in policy. Stigmatization can be reinforced by media portrayals and public attitudes and behaviors and can lead to the patient concealing their pain and/or social isolation. Public policy, such as the National Pain Strategy in Australia, can propose more comprehensive education and training in pain management. In the U.S., a primary focus should be to educate and change public views toward chronic pain. In fact, the Institute of Medicine report, Relieving Pain in America, called for "a cultural transformation in the way pain is viewed and treated." This may require the entire pain community to adopt and promote an integrated biopsychosocial model. Government task forces in the U.S. have suggested that if pain persists beyond three to six months, or the normal time of healing, then a biopsychosocial informed treatment should be used.

The evidence supporting the effectiveness of these three strategies is largely lacking (Cosio & Demyan, 2021a).

Chronic Pain Management in Marginalized Populations

Research has robustly demonstrated that minoritized patients present with higher pain prevalence rates and experience less adequate assessment, treatment, and outcomes compared to their majority counterparts. Incorporating cultural competence, also referred to as cultural responsiveness, into clinical practice has been introduced as a vital method to address these health disparities. Traditional approaches to multicultural training often focus on promoting clinician awareness of social and cultural influences on patients’ health outcomes. More recently, the approach has emphasized providers’ commitment to self-reflection, self-critique of bias and discrimination, and attention to power imbalances in the patient-provider relationship.

Intersectionality. Another development toward cultural responsiveness includes an understanding of the patient’s multiple cultural identities, referred to as "intersectionality." Intersectionality describes the simultaneous experience of categorical and hierarchical identity classifications including, but not limited to race, class, gender, sexuality, and nationality. Intersectional theory asserts that people are often disadvantaged by multiple sources of oppression. An intersectional approach allows for the complex conceptualization of multiple cultural identities to address health disparities. Initially, the work of intersectionality was developed to address the unique experiences of Black women relative to both Black men and white women; the concept has since been expanded to address a range of social identities.

Intersectionality requires a shift in provider thinking from dominant frameworks to frameworks that are mindful of how one’s positions of culturally sanctioned privilege and/or oppression operate within an interpersonal patient-provider context. The first step is to recognize the ways in which these axes of identity and structural inequalities come together sometimes to yield unexpected (to the provider) pain presentations. Past research has demonstrated that cultural identities impact access to treatment, patient-provider communication, treatment planning, response to treatments, and health outcomes for chronic pain patients. The opportunity to address this oppression exists in all levels of medical care with the goal of increasing accessibility of care, improving the predictability of getting appropriate care (patient expectations), and enhancing feelings of safety for all patients with chronic pain. Thus, it is important for practitioners to understand the nuanced way pain can be communicated and assessed across identities. It is important for healthcare providers to reflect on their own biases and stereotyping, and how this may inhibit assessment and treatment decisions.

NOTE: The following is a brief review of the literature, as it currently stands, about the relationship between each axis of privilege and chronic pain. We acknowledge that each axis could be a sole focus of its own. This summary is to create broad awareness and motivate providers to self-assess personal biases in order to enhance cultural responsiveness.

Axes of Privilege

Sexism/Genderism. Sex differences in pain sensitivity have been well documented, such that cisgender women often report greater sensitivity than cisgender men. A recent study also found that cisgender women’s pain is more often psychologized, leading to stigma, and noted the greater stoicism of cisgender men. Clinical reports highlighting sex differences often equate gender and sex. This is a particularly critical oversight for those whose gender identity is different than their genetic sex. When it comes to transgender and/or gender non-binary individuals, increased pain, especially in the areas of the body that change as a result of cross-sex hormone treatment, is often experienced. There is also data that supports the notion that gender identity may also play a significant role in pain sensation. One recent study found that transgender women and cisgender women similarly reported greater chronic pain severity compared to cisgender men. These results indicate that treatment should be based on both gender identity and genetic sex distinct variables.

Racism/Ethnicism. There is genetic and biological support for variability in the experience of pain. Nevertheless, cultural values also significantly inform the expression of nociception. Importantly, racial discrimination has been found to increase pain conditions and pain sensitivity. Despite this, all racial/ethnic minoritized patients are less likely to get pain medication compared to their White counterparts. The following is a more focused summary of the literature for chronic pain management and its effect on each racial/ethnic minoritized group:

• Asian/Pacific Islanders: Research reports, on average, greater pain sensitivity in Asian patients compared to other racial/ethnic minoritized groups. However, Asian patients have been found to be less likely to receive a pain assessment when compared with White patients. Racial discrimination for Asian patients has also been associated with pain conditions and indicators of pain. Furthermore, findings suggest that psychological distress is often communicated as physical pain in Asian populations.

• Black/African Americans: Patients who are Black have been found to have higher rates of pain and pain sensitivity, particularly in instances of racial discrimination. There are many myths and stereotypes that are prominent among medical students and residents regarding a Black patient’s experience of pain. Thus, Black patients have been found to experience the highest rates of analgesic treatment disparity compared to other racial/ethnic minoritized groups, receiving significantly less opioids across pain types and treatment settings despite not being more at risk of pain medication dependence.

• Latinx/Hispanic/Latinos: Latinx individuals report higher pain levels when compared to White patients on standardized pain stimuli. Racial discrimination was found to have a significant, indirect effect on pain intensity and disability via anxiety sensitivity in a sample of Spanish-speaking Latinos. While Latinos have been found to value stoicism in the face of pain, it is also common for Latinas to moan and cry as an expression of pain. Providers might see these unfamiliar expressions as exaggerations of pain and interpret them as medication seeking, when they may actually be culturally sanctioned expressions of pain.

• Indigenous/Native Americans: Pain anxiety in indigenous populations has been found to contribute toward increased pain. Native Americans had the highest rates of physician perceived pain exaggeration. In contrast, a recent investigation found that Native Americans were less pain sensitive than their White counterparts in their pain responses. (Palit, et al., 2013) These have been found to leave Native Americans’ pain undertreated.

Heterosexism. Little research exists about the prevalence rates of chronic pain disorders among the LGBTQIA individuals. Past research has shown that sexual orientation (Hetero-, Homo-, Bi-sexual) disparities in chronic pain were partially explained by associated factors, including childhood abuse, depressive symptoms, suicidal ideation, lack of social support, and self-esteem. The biggest hurdle for this community is finding appropriate medical care. Anti-LGBTQIA discrimination and heterosexism have been noted by medical students, yet they report a high level of comfort and confidence providing health care to LGBTQIA patients.

Ableism. Unfortunately, without an adequate understanding of pain and its mechanisms, many providers downplay the experience of their patients as faking or exaggerating, which translates into denying a disability because it is "invisible." Outcome studies have been complicated by the discrepancies between pain, impairment, and disability inherent in chronic pain populations. To assist with these discrepancies, the World Health Organization released an International Classification of Illness in 1980, which outlined the difference between the terms "pathology," "impairment," "disability," and "handicapped."

Educationalism. The impact of education on health outcome has been found to be significant. In fact, a recent study found that patients in the U.S. who are without a college degree report more chronic pain than those who are college graduates. (Case, Deaton, & Stone, 2020 ) Findings suggests that lower education attainment many times is linked to socioeconomic stressors that can lead to chronic pain and/or barriers to access to adequate healthcare services.

Classism. Class status, or socioeconomic status (SES) has been found to have a stronger impact on the risk of chronic pain compared to other axes of privilege, such as those based on race/ethnicity. Midlife and older adults with greater wealth are less likely to experience high-impact chronic pain and also have access to higher-quality health care. Similar to bias with pain patients based on race/ethnicity, providers appear more suspicious of medication-seeking in lower SES patients. For example, they more often use opioid contracts with low-SES compared to high-SES patients.

Ageism. Older adults might deny pain if preferred terms are not applied in the assessment. Asking simple, concrete questions, one at a time, at a slow pace will help increase the accuracy of the pain assessment. Furthermore, pain behaviors need to be evaluated and observed, including facial expressions, rigid or tense body movements, changes in interpersonal interactions (including aggression and withdrawal), changes in routines, and mental status changes. Conditions such as dementia may make pain assessment more complex. Including family members and caretakers in the assessment process can help increase accuracy. See Herr, et al. (2006) for a review of several pain assessment tools for use with older adults with dementia.

Language Bias. There is a lack of research on pain treatment in non English speaking patients. While bringing a third party to interpret can be beneficial, providers experience this as an additional complexity that challenges communication accuracy. In order to increase quality of care to non English speaking patients, providers should reflect on their initial reactions to select languages and accents and note any biases. Providers should aim to use official interpreters or technology to increase communication accuracy. Furthermore, nonverbal assessment measures can also be used such as the Wong-Baker Faces Pain Rating Scale, which has been translated into more than 50 languages.

Religion/Prevailing Beliefs. The most common religion in the world continues to be Christianity, with Islam as the world’s second largest religion. Yet, many health practitioners are unfamiliar with Islam and other religions/ prevailing spiritual beliefs. Muslims, for example, may not want to take medications that impair cognitive abilities without an understanding of its necessity. Importantly, religious coping has been found to be an effective treatment for Muslim women with chronic pain from fibromyalgia and breast cancer. Research that investigates the impact of Abrahamic religions on pain is lacking. One exception, albeit several decades old, found that patients who are Jewish have been found to have similar responses to pain as other ethnic groups. More research is needed to better serve the unique needs of patients from minoritized religious identities.

Improving Assessment and Treatment. People who are indigenous, recent immigrants or refugees, of color, LGBTQIA, less well-educated, living with mental health or substance-use challenges, or who have experienced violence and trauma, among others, are vulnerable to a higher prevalence of painful medical conditions relative to nonmarginalized people. While one cultural identify might be most salient for a patient, the ways in which multiple identities come together, or intersect, has been found to be an important predictor of pain communication and provider bias and discrimination, significantly impacting the quality of assessment and treatment.

For example, imagine two different patients are female-bodied and come from the same minoritized ethnic group. However, one identifies as heterosexual, middle class, and is older than the other patient who identifies as homosexual, working class, and is in an earlier stage of life. They may have similar sex/gender and racial/ethnic identities, yet differ across several other axes. In such circumstances, attention to intersectionality will lead the provider to acknowledge the patient’s uniqueness and understand the need to listen and act with cultural responsiveness. Through this collaboration with the patient, providers learn about the impact of their patient’s cultural identities on chronic pain expression and pain experiences, and can more accurately and effectively assess and treat pain in minoritized patients.

Incorporating cultural competence and humility into clinical practice has been the medical field’s approach to confronting health disparities. Providers need to utilize strategies for decreasing their own bias, which include an increased self-awareness around personal values and bias toward others’ values and an awareness of the spectrum of how pain experiences are expressed affectively. It is also important for providers to be familiar with the research contradicting the myth that minoritized patients are more likely to exaggerate pain and seek medication compared to White patients. While important, these approaches have been criticized for failing to fully address broader structural and institutional systems that perpetuate inequality and shape health outcomes. Moreover, a compassionate system that values equity with accountability is needed (Cosio & Demyan, 2021b).

Changes to the Diagnostic and Statistical Manual of Mental Disorders-5

The opioid epidemic reflects a serious unmet need for better recognition and treatment of common mental health problems in patients with chronic pain.

Frontline practitioners may at times be faced with chronic pain patients suffering from undiagnosed mental health disorders when tapering opioid therapy. In most cultures, the majority of mental health cases go unrecognized in primary care settings. About 60% of previously undetected cases could have been recognized if the patients had been evaluated for mental health disorders. Complicating these assessments is the fact that patients attending pain specialty clinics often have more difficult-to-treat pain conditions and comorbid psychiatric disorders, use more outpatient services, and receive a greater number of opioid prescriptions. These data support the inclusion of mental healthcare in the specialized treatment of chronic pain.

Numerous studies have documented a strong association between chronic pain and psychopathology. One pivotal study in 1986 delineated the distribution of assigned diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) published by the American Psychiatric Association for 283 male and female chronic pain patients. (Fishbain, et al., 1986) Each participant completed an extensive three day evaluation period as part of the admission to the Comprehensive Pain Center of the University of Miami School of Medicine. Each participant completed two hours of detailed, semi-structured psychiatric interviews based on DSM-III. The results of the study found that anxiety and depressive disorders were the most frequently assigned diagnoses. Males were significantly overrepresented with intermittent explosive disorders, adjustment disorders, and alcohol abuse and other drug dependence. Females were significantly overrepresented with depressive and somatization disorders.

In 2018, Cosio and colleagues conducted a pilot study that compared the APA’s 5th Edition of the DSM (DSM-5) disorders using emerging measures among Veterans who suffered from chronic pain. A sample of 272 Veterans ranging from 18 to 89 years old, with mixed, idiopathic conditions (i.e., back, neck, extremity, head, and fibromyalgia) were recruited from the local VA medical center. Sleep problems, somatic symptoms, and anger were the most frequently endorsed domains. Depression, anxiety, and memory problems were the second most reported with more than half of the sample endorsing the domains. The percentage of endorsers of all the domains was significantly different from the original 1986 study aforementioned, with the exception of the anxiety and substance -use domains. With the release of the DSM-5, the way in which the healthcare community defines these diagnoses has been reformed and, in turn, it may change how these domains are represented in the chronic pain population (Cosio, 2018b).

The next section describes each mental health diagnosis and its relationship with chronic pain in order to help pain providers learn more about these disorders, how they are defined, and how the definitions have changed with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, 2022).

WARNING: The description of the DSM-5-TR disorders that follows are in a highly simplified and summarized form. They are meant to give a quick overview and a reminder of the disorder (Buser, 2014). Please consult the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, 2022) for a more detailed description of the disorders.

Chronic Pain and Common Psychopathology

Depressive Disorders

DSM-5-TR: The diagnosis of depression is identified when five significant symptoms for the previous two weeks are presented [sadness, interest loss, guilt or worthlessness, energy loss, concentration loss, appetite change, psychomotor agitation or retardation, sleep change, suicide thoughts]. The diagnosis of major depressive disorder is based on the presence of a single or recurrent episode, current severity, psychotic features, and remission status. Depressive disorders include several other diagnoses, including premenstrual dysphoric disorder, substance-induced depressive disorder, and depressive disorder due to another medical condition. The DSM-5 also contains a few new depressive disorders, including disruptive mood dysregulation disorder and some modified disorders such as persistent depressive disorder (previously referred to as dysthymic disorder).

Depression and Chronic Pain. Depression is the mental health disorder that has generated the most research and theoretical interest among people who suffer from chronic pain. It is the fourth leading cause of disability worldwide. The 12-month prevalence of major depressive disorder in the U.S. is approximately 7%, with marked differences by age group (18- to 29-year-olds suffer at a rate three times higher than those over 60) and sex (females suffer at a rate 1.5 to three times higher than males). In a recent literature review, the prevalence of pain symptoms in patients with depression ranged from 15% to 100% (mean 65%). The mean prevalence for concurrent major depression in patients identified as having pain ranged from 5% to 10% (in primary care) to 85% (in dental clinics addressing facial pain) – creating almost a linear increase in the prevalence of depression from community to inpatient medical samples.

Investigators have found that when a pain condition is more defined (e.g.,peripheral neuropathy) there is less depression reported compared with medically unexplained pain. By contrast, research also indicates that pain symptoms are associated with at least a two-fold increased risk for coexisting depression. In addition, patients with multiple pain symptoms are three to five times more likely to be depressed than patients without pain. The association between depression and pain also strengthens as the severity of either condition increases.

Depression has been associated with an array of poor pain outcomes and worse prognoses. The prognosis of comorbid depression and pain is poor compared with the prognosis for individuals with depression without pain. In fact, a recent population-based study found that persons with concomitant depression and pain initiated more visits to medical providers and had higher total medical costs than persons with only depression. Patients with comorbid depression and pain experience more challenges in developing self-management skills. Depression and chronic pain exacerbate one another, share biological pathways and neurotransmitters, and respond to similar treatments. Thus, a pain treatment model that incorporates the assessment and treatment of depression seems necessary for optimal outcomes.

Assessing Depression. Patients who suffer from comorbid depression and pain often are referred to specialists with expertise in treating either condition rather than to a provider who is comfortable in treating both. Therefore, there are a few notable assessments that providers can use to help make treatment decisions. A variety of instruments have been used to screen/assess for depression, including:

• the Beck Depression Inventory;

• the Center for Epidemiological Studies-Depression Scale;

• the Geriatric Depression Scale; and

• the Patient Health Questionnaire (PHQ-9).

Some of the symptoms of depression and pain also overlap, such as difficulty sleeping, poor concentration, low energy, psychomotor retardation, and decreased interest. Therefore, practitioners should consider only the affective-cognitive symptoms when screening for depression in medical settings. A common experience during depression and pain is suicidality, which represents a critical concern in health care. Over 30,000 suicides occur each year in this country, and it is now the 10th leading cause of death for all ages in the U.S. Thus, medical providers need to screen their patients who suffer from pain for depressive symptoms and suicide, and facilitate a referral to a mental health professional for treatment if needed. Providers must also keep in mind how daily opioid use to treat pain sometimes has been associated with more severe pain, greater disability, and more frequent depressive symptoms in the long term, especially when prescribed in high doses. Since much of chronic pain management involves self-management, it is important for providers to remember that the effective treatment of depression can also facilitate the use of these practices.

Treatment of Depression. Management of these comorbid conditions can be broken down into four categories:

• Nonpharmacological – Includes psychotherapy, hypnosis, and biofeedback. According to Division 12 of the American Psychological Association’s Society of Clinical Psychology, there is strong research support for several psychotherapies for depression, some of which include behavior therapy/behavioral activation, cognitive therapy, cognitive behavioral therapy (CBT), interpersonal therapy, problem-solving therapy, self-management/self-control therapy, and acceptance and commitment therapy (ACT). Several other psychological treatments may also be effective in treating depression, but they have not been evaluated with the same scientific rigor as the treatments listed above. Interestingly, Division 12 also recommends CBT and ACT, among other interventions, for the treatment of chronic pain conditions. Psychological treatment as a whole results in modest improvements in pain and emotional functioning, but there is insufficient evidence to recommend one therapeutic approach over another, including biofeedback and hypnosis.

• Pharmacological – Includes Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), Norepinephrine Reuptake Inhibitors (NDRIs), atypical antidepressants, tricyclic antidepressants, and Monoamine Oxidase Inhibitors (MAOIs), as well as some antipsychotics. The medical management for chronic pain includes the use of antidepressants, mood stabilizers, anticonvulsants, and other analgesic agents. More specifically, meta-analyses have suggested that antidepressants result in moderate symptom reduction and are superior to placebos for the treatment of chronic noncancer pain. When choosing the appropriate medication to cover both conditions, providers should consider which agent will avoid polypharmacy, reduce side effects, and improve compliance with treatment.

• Interventional – Such as nerve blocks, spinal cord stimulators, or surgery should be considered carefully for the treatment of chronic pain. The management of severe, unresponsive-to-treatment depression can also include interventions that are more invasive, such as electroconvulsive therapy (ECT), and other noninvasive electrical stimulation therapies (i.e., transcranial magnetic stimulation and cranial electrotherapy stimulation).

• Integrated – Providers can also consider other collaborative, stepped-care, or integrated interventions, such as acupuncture and exercise, to improve both pain and depression outcomes. In addition, medical providers may want to consider a referral to an interdisciplinary rehabilitation program, which is the embodiment of the biopsychosocial model of care for patients with chronic pain. It has long been recognized that the complexities of chronic pain require the collaborative expertise of multiple disciplines (although the professional staff may vary), including pain specialists, physiatrists/recreational therapists, physical/occupational therapists, psychologists/social workers, pharmacists, and registered nurses (Cosio & Meshreki, 2017a).

Anxiety Disorders

Relative to depression, anxiety disorders have received less attention in the chronic pain literature. Interestingly, the aggregated association of anxiety disorders with chronic pain may be stronger than the association with depression. In the updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), the American Psychiatric Association (APA) moved post-traumatic stress disorder (PTSD) out of the chapter on anxiety disorders and put it into a new chapter. This reflects the recognition that PTSD is its own disorder, while still maintaining a close relationship with anxiety disorders, obsessive compulsive and related disorders (OCD), and dissociative disorders. Most prior pain research has evaluated the effects of anxiety disorders overall, including PTSD, on chronic pain and vice versa. Therefore, in this review, we present the research as such but include a specific section dedicated to the trauma and stress-related disorders after this section.

DSM-5-TR: The diagnosis of generalized anxiety disorder (GAD) is identified when the individual suffers from excessive worry most days for six months with three to six significant symptoms [restlessness, fatigue, decreased concentration, irritability, tenseness, and insomnia] and it interferes with work/social functioning. In addition to the creation of new sections for PTSD and OCD, the diagnoses of agoraphobia, specific phobia, and social anxiety have been updated. In addition, panic attacks now can be categorized as either expected or unexpected, rather than by type as outlined in the DSM-IV-TR. Furthermore, panic disorder and agoraphobia are no longer linked together, and are now recognized as two separate disorders. Childhood and adolescent anxiety disorders, such as separation anxiety and selective mutism, have been moved to the chapter on anxiety disorders.

Anxiety Disorders and Chronic Pain. Anxiety disorders cause distress in more than 30 million Americans in their lifetimes. The direct and indirect costs of anxiety disorders are estimated to be about $42 billion per year in the U.S. Anxiety disorders impair work, and social and physical functioning. There also appears to be an elevated prevalence of anxiety disorders among individuals with a variety of medical conditions, including arthritis. Earlier pain research listed the overall prevalence of comorbid anxiety disorders and pain as ranging between 16.5% and 28.8%. Newer studies suggest that anxiety disorders may be present in up to 60% of patients with chronic pain. Of course, these estimates are dependent on the methods used to assess for anxiety, the DSM criteria employed, and the spectrum of anxiety disorders included in the studies. In the U.S. National Comorbidity Survey Part II, anxiety disorders were present with chronic arthritic pain versus 17% of the general population. In the Midlife Development in the U.S. Survey (MIDUS), these findings were replicated and extended to persons with migraines and chronic back pain. Little consistency exists in the chronic pain literature about specific anxiety disorder diagnoses, but it appears that panic disorder and GAD are diagnosed most commonly. Panic disorder and pain share several psychological vulnerabilities, such as hyperarousal, somatic cues, and attentional biases, which may underlie both the anxiety and pain conditions. It also is possible that individuals use worry as a strategy for reducing somatic arousal associated with pain, making them more prone to developing GAD. In addition, studies have suggested that people with chronic pain may have a pre-existing anxiety disorder and/or report the onset of anxiety after experiencing pain. There is a growing understanding of the impact of anxiety and fear upon chronic pain and vice versa, and their overlap is common. More severe chronic pain has been associated with more severe anxiety symptoms. The presence of anxiety also has been shown to lead to more frequent reports of pain.

Assessing for Anxiety.The use of structured diagnostic interviews by trained mental health professionals is recommended to assess anxiety disorders among adults. Perhaps the most commonly recognized self-report measure used to assess for anxiety is the Beck Anxiety Inventory and the anxiety scales of the Brief Symptom Inventory. Some measures, such as the State-Trait Anxiety Inventory, are characterized more accurately as measures of general distress. Other instruments measure a specific diagnosis, such as the Mobility Inventory for agoraphobia, and some measure major symptoms particular to a diagnosis, such as the Penn State Worry Questionnaire, which measures worry in GAD.

Treatment of Anxiety Disorders. A variety of cognitive and behavioral treatment approaches have been studied for chronic pain and anxiety, including breathing control, muscle relaxation, exposure therapy, attention-diversion, desensitization, and hypnosis. According to the American Psychological Association’s (Division 12) Society of Clinical Psychology, the treatment of anxiety consists primarily of cognitive and behavioral therapies (CBTs), regardless of the particular type of anxiety disorder. CBTs have the strongest research support for the treatment of anxiety. Acceptance and commitment therapy (ACT) has been found to have modest research support for mixed anxiety conditions. For panic, CBT remains the treatment with the strongest research support. However, applied relaxation and psychoanalytic treatments have been found to have modest research support, although they are somewhat controversial. For specific phobias, exposure therapies – directly facing a feared object, situation, or activity – have been found to have the strongest research support. Four major classes of medications also may be helpful in the treatment of anxiety disorders, including:

• selective serotonin reuptake inhibitors (SSRI);

• serotonin-norepinephrine reuptake inhibitors (SNRI);

• tricyclic antidepressants (TCAs); and

• benzodiazepines.

However, when treating anxiety in people who suffer from chronic pain, prescribing a benzodiazepine and an opioid concurrently generally is discouraged. In August 2016, the FDA added a new black box warning for all opioid and benzodiazepine products that discusses “serious risks associated with using these medications at the same time, including the risk of extreme sleepiness, respiratory depression, coma, and death.” The treatment of anxiety also can include interventions that are more invasive, such as electrical stimulation therapies (cranial electrotherapy stimulation). A referral to a mental health professional is recommended for an accurate diagnosis and discussion of various treatment options. Providers also can consider other complementary and alternative interventions, such as acupuncture and exercise, to increase reconditioning of chronic pain symptoms and ameliorate anxiety outcomes (Cosio & Meshreki, 2017b).

Trauma- and Stressor-Related Disorders

Trauma- and stressor-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. The trauma- and stressor-related disorders include reactive attachment and disinhibited social engagement, PTSD, acute stress, adjustment, and other trauma- and stressor-related disorders.

DSM-5-TR: Criteria for PTSD differ significantly from those in DSM-IV. Criterion A was broadened to include traumatic events that were experienced directly, indirectly, or witnessed by the individual, and the subjective reaction criterion was eliminated (feelings of fear, helplessness, or horror). There now are four symptom clusters in DSM-5: reexperiencing, arousal, avoidance, and persistent negative alterations in cognitions and mood. Furthermore, DSM-5 adds separate criteria for PTSD in children six years old or younger. The other Trauma- and Stressor-Related Disorders diagnoses are used when full criteria of PTSD is not met. DSM-5 criteria for acute stress disorder also differ significantly from those in DSM-IV; as with PTSD, Criterion A for acute stress disorder is now more explicit. Since acute post-traumatic reactions are heterogeneous, an individual may meet diagnostic criteria if they exhibit any 9 to 14 symptoms related to intrusion, negative mood, dissociation, avoidance, and arousal. Adjustment disorders were reserved in DSM-IV as a residual category for individuals who exhibited clinically significant distress without meeting the criteria for a more discrete disorder. However, in DSM-5, adjustment disorders have been re-conceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing event.

Trauma- and Stressor-related Disorders and Chronic Pain. Common sequelae that follow a traumatic event include chronic pain and PTSD. Earlier studies reported a prevalence of PTSD among chronic pain patients as 1.7%. However, about 10% of Veterans referred to a pain clinic and 10% of patients attending a multidisciplinary chronic pain center have been shown to meet criteria for PTSD. Approximately 35% of injured workers referred to a rehabilitation program and about 30% to 50% of patients whose pain is secondary to a motor vehicle accident report symptoms of PTSD. Studies also suggest that hospitalized burn patients have been found to have high rates of PTSD (45%) 12 months post injury. Studies examining the prevalence of chronic pain in individuals with a primary diagnosis of PTSD have reported even higher co-prevalence rates. Pain is the most common physical complaint among patients who suffer from PTSD. Research has shown that anywhere from 60% to 80% of Veterans with PTSD report that they have a chronic pain condition. Research indicates that patients with chronic pain related to trauma or PTSD experience more intense pain and affective distress, higher levels of life interference, and greater disability than their counterparts without trauma or PTSD.

Assessing for PTSD. PTSD can be diagnosed accurately by a trained mental health professional. The gold standard assessment is the Clinician Administered PTSD Scale for the DSM-5 (CAPS-5), which employs an interview with the patient about trauma and PTSD symptoms. Throughout the course of therapy, the PTSD Checklist for DSM-5 (PCL-5) can be used to monitor PTSD symptoms and as a screening tool. The National Center for PTSD website (https://www.ptsd.va.gov/) provides helpful information for both the public and professionals. There also is a Primary Care-PTSD screen assessment available.

Treatment for PTSD and Pain. A multidisciplinary treatment approach to pain has been found to be the most effective method for patients with comorbid chronic pain and PTSD. Several of the more common causes of chronic pain include traumatic events; thus, it is not unusual for patients presenting with chronic pain to also describe significant levels of distress including PTSD. The multidisciplinary treatment model should emphasize helping patients see how the traumatic event may be linked to both their chronic pain and PTSD. Psychotherapy is the most effective therapy for patients with both pain and PTSD. Patients may benefit from CBTs (exposure therapy, pacing, and activity scheduling) to alleviate both conditions. According to the APA, the therapies that have the strongest research evidence for the psychological treatment of PTSD are:

• Prolonged Exposure (PE) – Based on the notion that repeated exposure to trauma-related thoughts, feelings, and situations can help reduce distress. PE consists of imaginal exposures (recounting the traumatic memory and processing the revisiting experience) and in vivo exposures (repeatedly confronting trauma-related stimuli that were previously avoided).

• Cognitive Processing Therapy (CPT) – Based on the notion that by changing the content of cognitions about a trauma, one can impact emotional and behavioral responses to the trauma. CPT focuses initially on the question of why the trauma occurred and then the effects of the trauma on the patients’ beliefs about themselves, others, and the world. CPT may improve pain-related function and pain scores among Veterans suffering from PTSD and chronic pain.

Another controversial therapy with growing research evidence is eye movement desensitization reprocessing (EMDR). EMDR is based on the notion that PTSD symptoms result from insufficient processing/integration of sensory, cognitive, and affective elements of the traumatic memory. Bilateral eye movements (proposed to facilitate information processing/integration) are paired with cognitive processing of the traumatic memories. Studies that have compared EMDR to exposure therapy without eye movements have found no difference in outcomes. Thus, it appears that while EMDR is effective, the mechanism of change may be exposure, and the eye movements may be an unnecessary addition. Although not as effective as psychotherapy, medications may help manage PTSD symptoms. These medications, which act on neurotransmitters involved in the fear and anxiety circuitry of the brain, include SSRIs, mood stabilizers, atypical antipsychotics, and benzodiazepines, among other agents. Again, use of a benzodiazepine with an opioid is discouraged. Most of the time, medications do not entirely eliminate symptoms but provide symptom reduction; they have been shown to be more effective when used in conjunction with psychotherapy.

In cases of comorbid PTSD and substance use disorder, Seeking Safety has been shown to have strong research support. Seeking Safety is a present-focused therapy to help people attain a feeling of safety from trauma/PTSD and substance abuse. Other psychological treatments also may be effective in treating PTSD, but they have not been evaluated with the same scientific rigor as the aforementioned treatments. Of course, a referral to a mental health professional is recommended for an accurate diagnosis and discussion of various treatment options (Cosio & Meshreki, 2017b).

Somatic Symptom Disorders

The diagnosis of somatoform disorder in DSM-IV had several shortcomings which were identified in past research:

• the terminology was unacceptable to patients;

• the diagnosis was inherently dualistic;

• the disorders were not coherent together;

• the diagnoses were incompatible with other cultures; and

• the diagnoses were ambiguous, unreliable, and lacked clarity.

Until now, somatoform disorder was believed to only represent the “tip of the iceberg” of persons who somatize. It was thought that somatization had a spectrum of severity, with somatoform disorder at one extreme and subsyndromal forms at intermediate and lower levels of complaint. Thus, the DSM-5 replaced somatoform disorders with SSD and made significant changes to the criteria. The DSM-IV term “somatoform disorders” was confusing and was replaced by the DSM-5 term “SSD”. In DSM-IV, there was a great deal of overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses which made it difficult to understand and use. The current DSM-5 recognized the overlap of diagnoses, and reduced the total number of disorders, as well as their subcategories. Several DSM-IV disorders, such as somatoform, undifferentiated somatoform, somatization, and pain disorders, have been re-categorized in a SSD dimensional scale ranging from mild to severe.

Patients who suffer from SSD are often given inappropriate diagnoses, treated for non-existent depression, and are exposed to multiple, superfluous interventions. In addition, the International Statistical Classification of Diseases and Related Health Problems (ICD-10) classification still defines somatization as “repeated presentation of physical symptoms, together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis.” Somatic symptoms that are not well explained are also oftentimes classified in medicine as functional somatic syndromes.

Furthermore, providers may still encounter some of the old diagnoses in patient’s charts and would benefit from a review of how the old diagnoses are distinct from one another. It is common for providers to use the terms malingering, factitious disorder, and somatization interchangeably. This is a group of illnesses where the patient reported symptoms that have no medical explanation. When they see these diagnoses, providers jump to the conclusion that a patient is “faking it,” oftentimes without gathering sufficient evidence to support that conclusion. These diagnoses differ in whether the patient is deliberately misleading the physician and agreeing to unnecessary treatments and diagnostics tests.

DSM-5-TR: The SSD criteria no longer require a specific number of complaints from four symptom groups. The DSM-5 criteria emphasize instead the degree to which a patient’s thoughts, feelings and behaviors about their somatic symptoms are disproportionate or excessive, such as in cases of heart disease or cancer. Thus, the diagnosis of SSD can occur in the context of a serious medical illness, much like depression. This change emphasizes how the DSM-5 removed the mind-body separation implied in DSM-IV, and encourages providers to make a comprehensive assessment and use clinical judgment. The new chapter of SSD contains several disorders, including illness anxiety (or hypochondriasis), functional neurological symptom (or conversion), factitious, and psychological factors affecting other medical conditions (such as pain). These newly conceptualized diagnoses have been found to be more useful for primary care and other medical providers than for psychiatric and other mental health clinicians, perhaps because the reporting of somatic symptoms is viewed by patients as a more appropriate route for seeking treatment.

Somatic Symptom Disorder and Chronic Pain. About 80% of the general population reports somatic symptoms during the past week. Somatic symptoms that are not well explained account for about a quarter to a half of presentations in both primary care and secondary consultations. However, these somatic symptoms are now not considered “disordered” unless they are associated with significant distress and impairment (abnormal thoughts, feelings, and behaviors). A key change in the new DSM-5 criteria is that while medically unexplained symptoms were a key feature for many of the disorders in DSM-IV, a somatic symptom disorder (SSD) diagnosis no longer requires that the somatic symptoms be medically unexplained. This follows the notion that the absence of a medical explanation for the somatic symptoms’ existence is not enough nor an appropriate criteria to give an individual a mental disorder diagnosis. A number of factors may contribute to SSD. These include:

• genetic/ biological vulnerability (increased sensitivity to pain);

• early traumatic experiences (violence, abuse, and deprivation);

• learning (attention obtained from illness and lack of reinforcement of other expressions of distress); and

• cultural/social norms (devalue and stigmatize psychological suffering as compared with physical suffering).

The precise prevalence of these disorders is generally unknown. The prevalence of SSD is expected to be around 5%-7% in the general population. The frequency of the diagnosis is believed to be higher than DSM-IV’s somatization disorder (<1%) and lower than that of undifferentiated somatoform disorder (~19%). The one- to two-year prevalence estimates of illness anxiety disorder in community surveys and population-based samples ranges from 1.3%-10%; and the six-month to one-year prevalence rates in ambulatory medical populations are between 3% and 8%. The incidence of referrals for functional neurological symptom disorder to neurology clinics is approximately 5%; and for individual persistent conversion symptoms is around 2- to 5 per 100,000 per year. It is estimated that about 1% of individuals have presentations that meet the criteria for factitious disorder in hospital settings. According to U.S. private insurance billing data, the prevalence of psychological factors affecting other medical conditions is more common than the other SSD’s.

There is relatively sparse research on SSD in chronic pain patients. The lifetime rates of the diagnoses in this syndrome in chronic low back pain samples are low and are comparable to rates found in community and primary care settings. The lifetime prevalence rate of the DSM-III somatoform pain disorder was 34% and a six-month rate of 17%, but dropped to 12% and 5% respectively when new criterion for DSM-IV was applied to the diagnoses. Another study found that more than 95% of patients with chronic low back pain in an intensive rehabilitation setting had current SSD. There is evidence also to suggest a correlation between pain intensity and the presence of somatization and hypochondriasis. The frequency of SSD in chronic pain patients varies from 0% to 53%. More specifically, the frequency of conversion disorder ranges from 2% to 38%. It is believed that the discrepancy may be due to the subjectivity of pain, but also due to how the diagnostic classification of somatization has changed over time.

Assessing for Somatic Symptom Disorder. A number of inventories have been utilized to measure somatization in the past, including the hypochondriasis scale of the Minnesota Multiphasic Personality Inventory (MMPI) and the Rating Scale for Somatic Symptoms. Other scales that may be helpful to use, include:

• the Symptom Checklist-90-R (evaluates a broad range of psychological symptoms);

• the Illness Behavior Questionnaire (delineates patients’ attitudes, affects, and attributions related to illness);

• the Illness Attitude Scale (assesses hypochondriacal fears and beliefs);

• the Prime-MD (Somatization Subsection);

• the Whitney Index (screens for hypochondriasis);

• the Health Attitude Survey (focuses on dissatisfaction with health and distress); and

• the Somatosensory Amplification Scale (measures sensitivity to bodily sensations).

Pain remains part of the SSD spectrum as a specifier. In 1996, the International Association for the Study of Pain defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” There are several key functions one should consider assessing for when dealing with pain, including pain intensity, pain quality, mood, personality characteristics, beliefs, coping, functioning, and quality of life. Determining which scale to use to measure these functions should be guided by the research question and the validity and reliability of the measure being considered.

Treatment for SSD and Chronic Pain. The diagnosis of SSD offers practitioners few specific guidelines about treatment beyond clinical management aimed at minimizing health care use and adverse effects caused by a medication or physician. However, antidepressants have been demonstrated to have analgesic properties in the treatment of SSD. Past structured evidence-based reviews have also concluded that SSD are improved by pain treatment.

Cognitive behavioral approaches have become widely accepted in the management of chronic pain. According to Division 12 of the American Psychological Association’s Society of Clinical Psychology, there is strong research support for cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT), among other interventions, for the treatment of chronic pain. Behavioral interventions also show long-term cost-effectiveness in the management of chronic pain. Psychological treatment, as a whole, results in modest improvements in pain and emotional functioning, but there is insufficient evidence to recommend any specific therapeutic approach (behavioral therapy, CBT, ACT, psychodynamic therapy, stress management, emotional disclosure, biofeedback, or hypnosis) over another. Although some psychological interventions may be effectively applied to all types of chronic pain, other psychological interventions may have greater effectiveness if targeted toward specific pain types or specific aspects of chronic pain conditions (Cosio, 2017a).

Personality Disorders

During the development process of DSM-5, several proposed revisions were drafted that would have significantly changed the method by which individuals with these disorders are diagnosed. Based on feedback from a multilevel review of proposed revisions, the American Psychiatric Association Board of Trustees ultimately decided to retain the DSM-IV categorical approach because the new method was deemed too complex for clinical practice. The proposed revisions that were not accepted for the main body of the manual were approved as an alternative, trait-specific, dimensional model. Thus, personality disorders are included in both Sections II (same criteria as found in DSM-IV) and Section III (proposed research model). In DSM-5, personality disorders represent maladaptive variants of personality traits that merge subtly into normality and into one another. Their integration, clinical utility, and relationship with the personality disorder diagnostic categories were developed by the DSM-5 Personality and Personality Disorders Work Group and various aspects of personality dysfunction are under active investigation. DSM-IV organized clinical assessment into five areas, or axes, addressing the different aspects and impact of disorders. This multiaxial system was introduced in part to encourage clinical and research focus on certain conditions, such as the personality disorders. As a consequence, these disorders were designated to Axis II to ensure they received greater attention. However, there is no fundamental difference between personality disorders and other mental disorders. Therefore, DSM-5 removed the arbitrary boundaries and shifted into a single axis system.

DSM-5-TR: Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible, maladaptive, and cause significant functional impairment or subjective distress do they constitute personality disorders. Personality disorders are defined as qualitatively distinct clinical syndromes, and previous diagnostic manuals (including DSM-IV) only used the categorical perspective as a diagnostic approach. The essential feature of a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas:

• cognition;

• affectivity;

• interpersonal functioning; and

• impulse control

Does a pain personality exist? Since the time of Aristotle, philosophers have noted the interaction between sensation and emotion. Patients with personality disorders have a tendency to overreact to stress, including disease, in the characteristic pattern of their personality disorder. Personality type characteristics are accentuated by the medical condition, in this case chronic pain. Therefore, these characteristics present predictable behavioral management problems. Over the past few decades, several theories have been proposed about personality in the chronic pain population.

The first theory was posed from a psychodynamic perspective by Engel in 1959. His theory postulated that underlying emotional conflicts shape personality features that inhibit the expression of emotional pain in an appropriate way. The next theory came from a trait theoretical approach, which focused on the objective and scientifically sound measurement of stable personality traits. Research from a trait theoretical approach found a large subgroup of chronic pain patients typically scored the “conversion-v” pattern, or elevation of the first three scales (Scale 1-Hypochondriasis, Scale 2-Depression, and Scale 3-Hysteria), on the Minnesota Multiphasic Personality Inventory (MMPI-2). With the advent of the biopsychosocial approach in the 1980s, the diathesis-stress model dominated the field. The model accentuates the interplay between an individual’s biological predisposition and the impact of the environment, such as stressors as a result of physical damage, to explain the different responses to chronic pain.

Cloninger’s temperament and character model is the latest theory being proposed. The model builds off of the diathesis-stress model and further differentiates between temperament and character. Temperament is defined as the emotional core of personality and is moderately inherited, while character describes the cognitive core of personality and is influenced by the environment. This model views personality along a continuum rather than using a categorical approach. This reflects the proposed research model for personality disorder diagnosis and conceptualization witnessed in the DSM-5. Research using Cloninger’s model has portrayed a common personality profile of chronic pain. Personality symptoms of cluster A have been found to be related to low reward-dependence; cluster B to high novelty-seeking; and cluster C to high harm-avoidance. For example, pain symptoms may function as an interpersonal means of eliciting caring responses from others in patients with borderline personality disorder. Overall, chronic pain patients are characterized by prevailing harm-avoidance and lower self-directedness.

Overall, it appears that chronic pain is associated with a particular personality profile. It also appears that different types of pain are associated with very similar psychosocial states. If the nature of the sensory pain experience is not relevant in the psychological experience of pain, then perhaps there is a mutual personality pain profile. Therefore, chronic pain treatment may shift in the future from targeting the sensory and psychological state to being focused on the psychological trait.

Personality Disorders and Chronic Pain. Past research suggest that between 9.1% and 15% of U.S. adults have at least one personality disorder, and individuals frequently present with co-occurring personality disorders from different clusters. The three personality disorder clusters (odd-eccentric, dramatic-emotional, and anxious-fearful) are based on descriptive similarities. The odd-eccentric (5.7% prevalence) include paranoid, schizoid, and schizotypal personality disorders; the dramatic-emotional (1.5% prevalence) include antisocial, borderline, histrionic, and narcissistic personality disorders; and the anxious-fearful (6.0% prevalence) include avoidant, dependent, and obsessive-compulsive personality disorders. It should be noted that this old clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.

The rate of personality disorders in the chronic pain population ranges between 30% and 60%. One study reported that 51% of patients with chronic pain met criteria for one personality disorder, and 30% met criteria for more than one. Another study found that 60% of persons with chronic pain met diagnostic criteria for a personality disorder, which was in contrast with the 21% of patients with acute low back pain who met diagnostic criteria. Typically, personality disorders are considered to predate the onset of injury and complicate the course of a pain syndrome. Past research has also noted that a significant number of persons with chronic pain syndromes specifically meet criteria for the cluster C personality disorders (e.g. dependent with 10.6% prevalence and obsessive-compulsive with 24.5% prevalence). There is also evidence to suggest there are high levels of prevalence of cluster B personality disorders in the chronic pain population. The range of borderline personality disorder specifically in the chronic pain population ranges between 9.4% and 58%, with an average of about 30%.

Assessing for Personality Disorders. The diagnosis of personality disorder traditionally was made by a mental health clinician who conducted an unstructured clinical interview with the patient. Although a single interview with the individual might be sufficient for making the diagnosis of a personality disorder, it is recommended to conduct more than one interview and to space these over time. Another recommendation may be to use a semi-structured interview which consists of a series of questions to be asked in a specific order. Assessment can also be complicated by the fact that the characteristics that define a personality disorder may not be considered problematic by the individual. To help overcome this difficulty, supplementary information from other informants may be helpful.

Some of the more widely used personality self-report measures are the Myers-Briggs Type Indicator, Neo Personality Inventory-Revised, 16-Personality Factor, Millon Clinical Multiaxial Inventory, the Schedule for Nonadoptive and Adaptive Personality, the Temperament and Character Inventory, and Eysenck Personality Questionnaire. In addition to self-report inventories, there are many other methods for assessing personality, including observational measures, peer-report studies, and projective tests, such as the Thematic Apperception Test or ink blots (Rorschach).

The most widely used objective test of personality is the MMPI-2, which was originally designed to distinguish individuals with different psychological problems. One of the strengths of using the MMPI-2 is that it has an additional psychometric property – validity, or correction scales that adjust for a person’s tendency to lie, deny, or exaggerate test responses. The MMPI-2 is also well-normed and extensively researched, and provides data about the patient’s test-taking approach. However, the MMPI-2 is not normed on pain patients, scales 1-3 are often elevated (the “conversion-v”) in pain patients, is lengthy, and requires a highly skilled evaluator to interpret the test results.

Treatment for Personality Disorders and Chronic Pain. Since personality disorders are so deeply ingrained from genetics and childhood, they have long been believed to be difficult to treat, especially the personality types in cluster B (antisocial, borderline, narcissistic, and histrionic). Some personality disorders are generally viewed as more treatable than others and use different types of treatment. It is believed that personality disorders are optimally treated simultaneously with combined psychotherapy and pharmacotherapy. Medication management is somewhat controversial in the treatment of personality disorders. It is important to note that there are no medications specifically approved by the FDA to treat personality disorders. This is because it does not cure the disorder itself, but instead reduces symptoms such as anxiety, depression, or psychosis. Despite the lack of endorsement, serotonergic antidepressants (SSRI, SNRI, TCAs) may be used.

The cluster A (schizotypal, schizoid, and paranoid) and the cluster C personality disorders (avoidant, obsessive-compulsive, and dependent) have been shown to respond the most to social skills training and medication management. Some personality disorders, especially those that involve psychosis, interfere with the sufferer’s ability to understand and read other people’s behaviors and feelings, and to respond appropriately. Social Skills Training is often done in groups and is a brief, targeted, educational treatment.

Perhaps the cluster B personality disorder with the most research is the borderline type. A recent study showed that 75% of borderline personality disordered patients showed great improvements in their symptoms 18 months after treatment ended. The treatment with the strongest research support is dialectical behavior therapy (DBT). DBT is a cognitive behavioral treatment that increases the patient’s ability to moderate between his/her intense emotions and actions. Its focus is a combination of mindfulness, interpersonal skills, distress tolerance, and emotion regulation. Cognitive behavioral psychotherapy (CBT) of chronic pain aims at diminishing misinterpretation of nociception, enhancing self-efficacy, and lessoning avoidance. mentalization-based treatment (MBT) and schema-focused therapy (SFT) also have modest research support for the treatment of borderline personality disorder. MBT is a form of psychodynamic treatment whose goal is to teach the patient how to “mentalize,” or picture/ imagine what others are feeling in response to his/her behavior. SFT challenges the maladaptive “schemas,” or beliefs/feelings, that the patient learned in childhood. SFT has also been shown to be effective for the other cluster B disorders (e.g., antisocial and narcissistic personalities) (Cosio, 2018c).

Substance-Use and Addictive Disorders

The substance-related disorders encompass 10 separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens (phencyclidine), inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants (amphetamines and cocaine), tobacco, and other (or unknown) substances. The substance-related disorders are divided into two groups: substance-use disorders (SUDs) and substance-induced disorders (intoxication, withdrawal, and other substance/medication-induced mental disorders). The essential feature of a SUD is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. The diagnosis of a SUD is based on a pathological pattern of behaviors related to use of the substance. To assist with organization, criteria can be considered to fit within four overall groupings: impaired control, social impairment, risky use, and pharmacological criteria. The new DSM-5 criteria for SUD are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list. Since DSM-IV was published in 1994, its approach to substance-use disorders has come under scrutiny. Strengths were identified, such as the reliability and validity of substance abuse dependence, but concerns also arose. Concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance-use disorder severity indicator could be identified.

DSM-5-TR: The biggest change witnessed in the DSM-5 is the way in which we diagnose the disorder. The DSM-5 moved away from the categorical approach (abuse versus dependence) to a dimensional scale. DSM-5 now uses a criteria count (from two to 11) as an overall severity indicator. The number of criteria met indicates the severity, with mild (two to three criteria), moderate (four to five), and severe (six or more) disorders The DSM-IV recurrent-legal-problems criterion for substance abuse was deleted and a new criterion, craving or a strong desire or urge to use a substance, was added to DSM-5. Early remission from SUD is now defined as at least three but less than 12 months without criteria, and sustained remission is defined as at least 12 months without criteria (except craving in both remissions). Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy,” as the situation warrants.

How are Substance-Use Disorders and Addiction Related? All classes of substances that are taken in excess directly activate the brain reward system. This system is involved in the reinforcement of behaviors and the production of memories. Illicit substances can produce an intense activation of that system, which then trigger the reward pathways and cause a “high,” and cause normal activities to be neglected. Furthermore, individuals with prior lower levels of self-control may be particularly predisposed to develop SUDs, which may reflect impairments of brain inhibitory mechanisms. Behavioral effects of SUD (repeated relapses and intense drug cravings) reflect brain changes that are evident even after detoxification when the individuals are exposed to drug-related stimuli.

Substance-Use Disorder and Chronic Pain. Chronic, noncancer pain is common among patients being treated for SUD, and a history of SUD occurs frequently among patients who receive treatment for chronic, noncancer pain. 3% to 48% of patients who suffer from chronic, noncancer pain have a current SUD. Lifetime prevalence rates (16% to 74%) have been found to be higher than that found in the general population (16.7%). Ninety-four percent of chronic pain patients with lifetime substance-use disorders experience the onset of these disorders before the onset of their chronic pain. Chronic pain patients are no more likely than any other patient in the primary care setting to have a current substance-use disorder, suggesting that chronic pain is not associated with unique risk for substance abuse. The most commonly abused substances in chronic pain patients seemed to be alcohol (current and lifetime) and narcotics (current). However, that is only when the traditional “illicit substances” are considered (not marijuana and tobacco). More specifically, current alcohol use has been found to be 4.3%, and 7.4% in remission, while current drug dependence (opioids, barbiturates, sedatives, and cannabinoids) was 10.6%, and 0.4% in opioid remission. Another study indicated that 23.4% of chronic pain patients met criteria for active alcohol (9.7%), analgesic (12.6%), or sedative use (7.0%), and an additional 9.4% were in remission.

Assessing for Substance-Use Disorders. There are several elements of a comprehensive patient assessment for SUD. In addition to a physical exam, an examination of co-occurring conditions and mental health disorders, and a mental status, the assessment should include an evaluation of the patient’s substance abuse history and risk for addiction. There are several factors involved in a substance use history evaluation, including:

• the current use of substances (including prescription medications) confirmed with the use of laboratory toxicology testing;

• adverse consequences of usage;

• the age at first use;

• treatment history (including AA/NA support groups);

• periods of abstinence;

• the strength of their recovery support network;

• family history of SUD; and

• history of physical, sexual, or emotional abuse or trauma.

Some providers may question the validity of self-reported drug/alcohol use. One study found that about 9% of chronic pain patients provided incorrect self-report information about current drug use, and the incorrect information was mostly about illicit drugs (i.e., cocaine and cannabis). Urinalysis remains the standard means of testing for drug use. However, the assessment of alcohol use is more complicated and may require the use of a breathalyzer. There are options for the assessment of alcohol use using instruments, which is more refined than for other substances. Several instruments are available for the measurement of alcohol use, including the Alcohol-Use Inventory, the Alcohol Dependence Scale, the Michigan Alcoholism Screening Test, the Addiction Severity Index, and the CAGE questionnaire.

Treatment for Substance-Use Disorders and Chronic Pain. There are several standards available that may be of assistance when considering the treatment of SUD, including:

• the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Substance-Use Disorders;

• the American Society of Addiction Medicine’s Patient Placement Criteria for the Treatment of Substance-Related Disorders;

• the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Nicotine Dependence;

• the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment; and

• the Division 12 of the American Psychological Association’s Society of Clinical Psychology.

Several psychotherapies have been found to have strong research support for SUD, including:

• Motivational Interviewing (MI) – A brief person-centered clinical method for strengthening patients’ motivation for and commitment to change. The overall spirit or style of MI is collaborative and empathic, and the course of MI is normally one to four sessions. MI therapists use a variety of strategies to evoke and strengthen patients’ “change talk.”

• Motivational Enhancement Therapy (MET) – Combines the clinical style of MI with individual assessment feedback that may be particularly helpful for less-ready patients, where the initial task is to develop ambivalence about change.

• Cognitive Behavioral Therapy (CBT) – MI and MET can be combined with other approaches such as CBT.

• Contingency Management (CM) – CM is a structured behavioral therapy that involves frequently monitoring the behavior targeted for change, and reinforcing the behavior each time it occurs using tangible and escalating reinforcers. Usually, CM is in effect for 8-24 weeks, and is typically provided as an adjunct to another treatment. It has been shown to have modest research support for the treatment of cocaine use disorder.

• Seeking Safety (SS) – A present-focused counseling model to help people attain safety from trauma and/or substance abuse. It is an extremely safe model as it directly addresses both trauma and addiction, but without requiring patients to delve into the trauma narrative. It can be conducted over any number of sessions available, although the more the better when possible.

When in reference to alcohol-use disorder specifically, there is also strong research support for behavioral couples therapy (BCT) for alcoholism. When delivering BCT to a married or cohabiting alcoholic patient, a therapist treats the substance-abusing patient with his/her intimate partner and works to build support from within the dyadic system for abstinence. When in reference to tobacco use disorder, smoking cessation with weight-gain prevention programs have modest research support. These programs are based in CBT, and address smoking cessation first, followed by weight control. It is also more effective to combine counseling with medication than either component alone.

Managing Addiction Risk in Patients Treated with Opioids. Many frontline practitioners are reluctant to prescribe an opioid for chronic pain management among patients with a SUD in fear of addiction, misuse, or diversion. This is in light of the fact that opioid abuse (9%) and illicit drug use (16%) have been found to be common in chronic pain patients. Thus, many providers implement different mitigation strategies in an attempt to reduce these occurrences. Several prescribers begin treatment by working their way up the pain analgesic ladder before prescribing opioids. Others attempt to identify red flags (doctor shopping, borrowing or stealing opioids, selling their prescriptions, prescription forgery, reporting lost/stolen medications, disproportionate pain, and/or negative interactions with other pain providers) to predict these occurrences. A common concern expressed by providers is how to distinguish a patient who is misusing opioids from the patient who is potentially addicted.

According to the new CDC guidelines for the initiation, selection, and assessment of opioid therapy risk released in March 18, 2016, clinicians should incorporate strategies to mitigate risk into the management plan, including an assessment and history of SUD. One study demonstrated that questions about family substance abuse history, past problems with drugs/alcohol abuse, and history of legal problems can be useful in predicting aberrant drug-related behavior with opioid use in persons with chronic, noncancer pain. Another recent study indicated the importance of considering current opioid prescriptions and sleep along with a substance use history in universal screening of patients with chronic pain for opioid misuse. There are several other mitigating strategies practitioners can use against opioid diversion and misuse. There are numerous screening tools available to help identify these patients, including the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Brief Risk Interview. The CDC has also recommended that prescribers use:

• data from the prescription drug monitoring program;

• urine drug screening;

• opioid pain agreements; and

• utilize universal precautions.

Presently, a combination of these strategies is recommended to stratify risk, identify and understand aberrant drug related behaviors, and tailor treatments accordingly. Unfortunately, only limited data are available regarding the efficacy of any of these strategies (Cosio, 2017b).

Chronic Pain and Other Psychiatric Conditions

Research has shown that chronic pain is most often associated with depression, anxiety, somatoform, personality, and substance-use disorders, but less is known about pain’s relationship with other mental health conditions, such as schizophrenia spectrum/psychotic, sleep-wake, bipolar, neurocognitive, obsessive-compulsive, and dissociative disorders. The following is a review of what is currently understood about the relationship between chronic pain and the lesser known mental health disorders.

Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia is more notable by its absence from the chronic pain population than anything else. This may be due to an unfortunate gap in the research. This is especially important when one considers that pain is associated with a reduced quality of life among patients with serious mental illness. Patients with schizophrenia have been found to have increased rates of serious medical problems, are less likely to know or understand their medical difficulties, and their medical care can be fragmented or inconsistent.

The schizophrenia spectrum disorders are organized along a gradient of psychopathology in the updated DSM-5, including schizotypal personality (also found under the personality disorders), delusional, catatonia, brief psychotic, schizophreniform, schizophrenia, and schizoaffective disorders. Substance/ medication-induced psychotic, psychotic disorder due to another medical condition, and other specified and unspecified schizophrenia spectrum disorders are additional classifications that are included.

The diagnosis of a schizophrenia spectrum disorder requires the exclusion of another condition that may give rise to psychosis. The schizophrenia spectrum disorders are defined by abnormalities in one or more “positive” and “negative” symptoms. “Positive,” or added on, symptoms (delusions, hallucinations, disorganized thinking /speech, trouble concentrating, and catatonia) are so called because they are thinking or behavior that the person with schizophrenia did not have before they became ill. “Negative,” or lost, symptoms (apathy, emotionless responses, reduction in speech, social withdrawal, impaired attention, anhedonia, sexual problems, and lethargy) are so called because they describe thoughts or behavior that the person used to have before the illness. Negative symptoms are not a typically recognized aspect of schizophrenia compared to the positive symptoms.

DSM-5-TR: Several changes have been made in the schizophrenia spectrum section of the new DSM-5. Criterion A for delusional disorder no longer has the requirement that the delusions must be non-bizarre. DSM-5 no longer separates delusional disorder from shared delusional disorder, and is now classified as an “other” specified schizophrenia spectrum and other psychotic disorder. Three catatonic symptoms (from a total of 12 characteristic symptoms) are now required to meet criteria to diagnose catatonia whether the context is a psychotic or other mental health disorder. Two changes were made to DSM-IV Criterion A for schizophrenia in the new DSM-5. In DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia. In addition, the individual must have at least one “positive” symptom. The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) were also eliminated due to their limited diagnostic stability, low reliability, and poor validity. The primary change to schizoaffective disorder is the requirement that a major mood episode be present for a majority of the disorder’s total duration after Criterion A has been met, which serves as a bridge between schizophrenia and major depression.

Schizophrenia Spectrum and Pain Insensitivity Debate. A review of the literature will uncover the pervasive debate that exists around whether individuals with schizophrenia have pain insensitivity. This phenomenon would have important implications for physical health, self-mutilation, homelessness, premorbid development, and affective flattening in individuals with schizophrenia. As early as 1911, Bleuler noted the presence of “complete” analgesia when patients with “schizophrenia” incurred serious injuries (i.e., removal of an eye, self-inflicted amputation of the phallus, and sitting on a hot stove). In 1919, Kraeplin observed individuals diagnosed with dementia praecox to often be less sensitive to bodily discomfort (i.e., uncomfortable positions, pricks of the needle, injuries, cigar burns, and self-injurious behaviors). In the 1930s and 1940s, Schneider reported “inhuman” self-injury with a lack of pain sensitivity among individuals diagnosed with schizophrenia. Reduced pain sensitivity was increasingly being reported in clinical experiences by surgeons and internists for a variety of medical conditions or procedures, including:

• 3rd degree burns;

• arthritis;

• cancer;

• fractures;

• intra-abdominal diseases;

• myocardial infarction; and

• surgery.

It has also been investigated in the laboratory using different types of painful stimuli, including:

• cold-pressor;

• electrical;

• imagined;

• pin prick/pressure;

• pinch;

• thermal; and

• warmth and heat pain.

There are a variety of biological explanations for this phenomenon, including being a result of antipsychotic medications, dysregulation of N-methyl-D-asparate (NDMA) receptor-mediated neurotransmission, excess endorphins, genetic predisposition, and motor deficits. However, there is little to no physiologic evidence supporting pain insensitivity in schizophrenia. There are also other hypotheses, including psychodynamic, psychological, and sociological.

It is more credible to assume that pain experience in schizophrenia is disturbed or distorted rather than absent. Pain insensitivity is believed to be related more to a different mode of pain expression than to a real endogenous analgesia. Schizophrenia is a mental disorder associated with communication and social impairments, and it may be those impairments which affect the reporting of pain. Most prior research has also failed to distinguish pain reactivity from pain sensitivity – absence of reactivity does not mean absence of sensitivity.

Schizophrenia Spectrum and Chronic Pain. The prevalence of schizotypal personality disorder in clinical populations seems to be infrequent 0%-1.9%), but higher in the general population (3.9%). The lifetime prevalence of delusional disorder has been estimated at around 0.2% with the most frequent subtype being persecutory. Brief psychotic disorder may account for 9% of U.S. cases of first-onset psychosis. The lifetime prevalence of schizophrenia appears to be approximately 0.3%-0.7%. Schizoaffective disorder is one-third as common, and the incidence of schizophreniform disorder is fivefold less than schizophrenia. The prevalence of substance/medication-induced psychotic disorder among individuals presenting with a first episode of psychosis in different settings is between 7% and 25%, and of psychotic disorder due to another medical condition between 0.21% and 0.54%.

The most common pain complaint among individuals diagnosed with schizophrenia is headaches. Moreover, in a study examining the frequency of pain complaints, 38% of patients who suffer from schizophrenia reported pain. In 1981, Watson and colleagues examined the relationship between pain and schizophrenia and found that patients do experience pain both from physical and psychological causes and the most common sites were head, leg, and back pain. More recently, de Almeida and colleagues (2013) purported that chronic pain was common in patients with schizophrenia, similar to the general population of a similar age. Birgenheir and colleagues (2013) investigated the rates of pain present in a sample of Veterans diagnosed with schizophrenia. They found that 47% reported some type of pain; 35% reported arthritis; 22% back pain; about 4% reported headache or neuropathic pain; and less than 2% reported migraine, psychogenic, or chronic pain. Patients with schizophrenia can present with bizarre sensory complaints, such as “pins and needles” or coenesthesia (unusual or debilitating bodily experiences that do not have an apparent somatic cause). These tactile hallucinations may be difficult to distinguish from other pain complaints.

Assessing for Schizophrenia. In addition to an interview and behavioral observation of the patient, a psychological evaluation frequently includes a Minnesota Multiphasic Personality Inventory (MMPI-II). Specifically, the Schizophrenia scale of the MMPI-II has been shown to differentiate chronic pain patients from psychotic and non-psychotic psychiatric patients by the profile of symptoms they endorse. Chronic pain patients tend to endorse somatic symptoms and items suggestive of depression and inertia, while patients suffering from psychosis endorse items reflecting bizarre and disordered thinking, social alienation, and defective inhibition; other psychiatric patients endorse depression, despair, thought disorganization, and social alienation. Acute symptoms of schizophrenia may be assessed using the Scales for the Assessment of Positive and Negative Symptoms.

Treatment of Schizophrenia and Chronic Pain. Patients with schizophrenia are often seen as difficult to effectively treat, and providers tend to focus on psychiatric over medical symptoms and concerns. Pain treatment is oftentimes considered to be of lower importance to the treatment of their psychiatric symptoms, which leads to their medical conditions being undertreated. Although patients with schizophrenia experience disparities in medical treatment, there are opportunities to improve care at different levels:

• The patient level – Morbidity and mortality can be reduced by evidence-based interventions targeting schizophrenia. Over the past several decades, medical and psychosocial treatments for schizophrenia have become more effective. Antipsychotics, also known as neuroleptics or major tranquilizers, are a class of medication primarily used to manage psychosis, principally in schizophrenia. Antipsychotic medications have sometimes been thought to have analgesic effects. In terms of psychotherapy, there is strong research support for social skills training (SST), social learning/token economy programs (SLTE), cognitive behavioral therapy (CBT), cognitive remediation (CR), and family psychoeducation (FP). SST uses the principles of behavior therapy to teach communication skills, assertiveness skills, and other skills related to disease management and independent living. SLTE programs are comprehensive behavioral programs in which participants receive reinforcers (such as tokens or points) for performing clearly defined target behaviors. CBT is similar to how it is used for other types of problems, including chronic pain. It involves establishing a collaborative therapeutic relationship, developing a shared understanding of the problem, setting goals, and teaching the person techniques or strategies to reduce or manage their symptoms. CR improves cognitive function through repeated practice of cognitive tasks and/or strategy training. CR addresses impaired neuropsychological aspects of an individual and plays an important role in the functional impairments seen in schizophrenia. FP treatment is catered to family members of a person with schizophrenia to participate in and they are the focus of the intervention. FP recognizes that families can have a significant impact on their relative’s recovery and functioning. There is only modest support for illness management and recovery (IMR), acceptance and commitment therapy (ACT), and cognitive adaptation training (CAT).

• The provider level – Care could be strengthened by improving communication among patients and providers. Since the research suggests that the absence of pain among patients with schizophrenia may be associated with communication and social impairments, providers may want to focus on improving these skills. In addition, communication can be strengthened by incorporating the perspective of the patient’s mental health provider.

• The systems level – Several different models of integrated care have been found to have strong research support for meeting the needs of patients with schizophrenia. For example, in Assertive Community Treatment, team members share a caseload, have a high frequency of patient contact, low patient-to-staff ratios, and provide outreach to patients in the community using a multidisciplinary team approach to intensive case management. Another program, Supported Employment, emphasizes the integration of employment and mental health services, rapid placement of individuals into jobs in the community, individualized job development, and ongoing job supports. Supported employment is an approach to vocational rehabilitation adapted for individuals with serious mental illness. The benefits of vocational rehabilitation are shared between schizophrenia and chronic pain. These advances have allowed patients to achieve improved levels of community functioning and independence (Cosio, 2017c).

Sleep-Wake Disorders

It is the classic chicken-or-egg problem to determine the direction of causation between pain and sleep disturbance. Both share common neurobiological systems, in particular the central serotoninergic neurotransmission. The new DSM-5 mandates that coexisting medical and mental conditions be independently specified when treating patients. This mandate acknowledges the bidirectional and interactive effects between coexisting medical and mental disorders. This conceptualization reflects a paradigm shift away from causal attributions which is widely recognized in sleep medicine. A sleep disorder, like chronic pain, may eventually become its own disease, or centralized.

The DSM-5 sleep-wake disorders are intended for use by general mental health and medical providers. The sleep-wake disorders encompass ten disorders, including insomnia, hypersomnolence, narcolepsy, breathing-related, circadian rhythm, nonrapid eye movement (NREM) sleep arousal, nightmare, rapid eye movement (REM) sleep behavior, restless legs syndrome (RLS), and substance/medication-induced sleep disorders. Insomnia is the most prevalent of all the sleep-wake disorders. It involves a subjective complaint of problems initiating and/or maintaining sleep, or nonrestorative sleep. There are four main types of sleep problems that can occur in insomnia, including sleep onset, sleep maintenance, early awakening, and/or mixed. Insomnia is associated with a range of problems, including clinically significant impairment or distress in social, occupational, and other important areas of functioning.

DSM-5-TR: The diagnosis of primary insomnia in DSM-IV has been renamed insomnia disorder to avoid the differentiation of primary and secondary insomnia. DSM-5 also distinguishes narcolepsy from other forms of hypersomnolence. The breathing-related sleep disorders were divided into three distinct disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. The subtypes of circadian rhythm sleep-wake disorders were also expanded to include advanced sleep phase syndrome, irregular sleep-wake type, and non-24-hour sleep-wake type. Rapid eye movement sleep behavior disorder and restless legs syndrome are now independent disorders originally under dyssomnia not otherwise specified in DSM-IV.

How are Sleep and Pain Related? A typical sleep pattern can be divided into five stages based on brain-wave patterns from EEG, or electroencephalography. The first four stages are called non-rapid eye movement (NREM) sleep while the last stage is called REM sleep. The sleep cycle lasts 100 minutes and recurs four to six times per night depending on the length of time one sleeps. Early REM are ten minutes long, but increase through the night. By the end of sleep, REM periods last up to 50 minutes. In contrast, delta sleep is longest early in the night and shorter at the end of the night.

In patients who suffer from chronic pain, a self-perpetuating cycle can be set in motion in which joint, myofascial, or musculoskeletal disease leads to fatigue, which leads to decreased aerobic exercise and physical deconditioning. As patients spend more time in bed, their basic circadian cycle is disrupted. As a result, the basic physiologic rhythm of sleep is lost. The lack of movement and sleep leads to more pain, further sleep disruption, dysphoria, and more fatigue. Sleep deprivation produces hyperalgesic changes according to the majority of past studies. Obtaining either less than six or more than nine hours of sleep was associated with greater next-day pain in the general population. The analgesic effect of sleep recovery is apparently greater than the analgesia induced by compounds in healthy volunteers. Circadian rhythms might also be altered by the timing of various factors, including naps, bedtime, exercise, and exposure to light. Exercise and phototherapy have been used to assist patients in sleep. For example, strenuous exercise during the day may promote better sleep, as long as it’s at least three hours before bedtime.

Sleep-Wake Disorders and Chronic Pain. About one-third of adults report insomnia symptoms, and 6%-10% have symptoms that meet criteria for insomnia disorder. In primary care, approximately 10%-20% of patients complain of significant insomnia symptoms. Approximately 5%-10% of patients consulted to sleep clinics are diagnosed with hypersomnolence. It is estimated that about 1% of the U.S. general population has episodes of sleep inertia. Narcolepsy-cataplexy affects less than 0.05% of the general population. Obstructive sleep apnea is very common, affecting 2%-15% of middle-aged and more than 20% of older adults. Central sleep apnea comorbid with opioid use occurs in approximately 30% of individuals taking chronic opioids for nonmalignant pain and similarly in individuals receiving methadone maintenance therapy. The prevalence of shift work type is estimated to affect 5%-10% of the night worker population.

The lifetime prevalence of sleepwalking in adults is 29%, with a past-year prevalence of sleepwalking of 4%. The prevalence of sleep terror episodes is approximately 2% in adults. The prevalence of monthly nightmares is 6% and 1%-2% for frequent nightmares among adults. The prevalence of REM sleep behavior disorder is approximately 0.5% in the general population. The prevalence rates of RLS range from 2%-7% when defined criteria are employed. Substance-induced sleep disorders can occur with alcohol, caffeine, cannabis, opioids, sedative, hypnotics, anxiolytics, amphetamines, stimulants, tobacco, and medications.

Studies suggest that 50%-70% of chronic pain patients suffer from a sleep disturbance, and at least 89% of patients seeking treatment for chronic pain report at least one complaint related to disturbed sleep-wake cycle. Sleep disturbances differ according to the pain syndrome with which they are associated, and the data about these disturbances are irregular. People with chronic insomnia reported more chronic pain (50.4%) then did people without insomnia (18.2%). Sleep apnea, restless leg syndrome, and periodic limb movements in sleep are the most commonly cited ailments that may have an association with pain conditions. Sleep apnea is diagnosed in 17% of headache patients, which exceeds population rates.

At least 60% of rheumatoid arthritis patients report sleep problems according to some data. Previous studies have also found increased arousals and sleep fragmentation in fibromyalgia patients compared to controls. The presence of comorbid primary sleep disorders, other than insomnia, in persons with chronic pain conditions has been found by several investigators. People with chronic pain reported more chronic insomnia (48.6%) than did those without chronic pain (17.2%). It is quite clear that pain impairs sleep – more than 50% of pain patients report significant sleep disturbance. However, there is evidence of a bidirectional relationship between pain and sleep. Increased daytime pain is linked with poor subsequent nighttime sleep and poor sleep is, in turn, associated with augmented next-day pain.

Assessing for Sleep-Wake Disorders. One must first begin with a careful medical history, which includes questions about time required to fall asleep, number and length of awakenings, length of time spent in bed after awakening in the morning, and length of time after arising before feeling sleepy again. There is also a need to add questions regarding bed type, sleep position, and patient’s sleep description. Also, providers may want to clarify caffeine intake, alcohol intake, and daily physical activity patterns. Some key questions should be related to specific sleep disorders, such as obstructive sleep apnea, narcolepsy, and restless legs syndrome. One may also recommend using a sleep diary, in which patients record their sleep habits on a daily basis. There are several scales and questionnaires one can use to assist in the retrospective assessment of sleep, including the sleep-interference visual analogue scale (from “strongly agree” to “strongly disagree”), the Pittsburgh Sleep Quality Index, the Pittsburgh Sleep Questionnaire, the Pre-Sleep Arousal Scale, the Epworth Sleepiness Scale, the Insomnia Severity Index, and the Sleep Disorders Questionnaire. A referral to a sleep medicine clinic or other provider who specializes in sleep disorders (e.g., psychologist) may be recommended for further assessment.

The diagnosis of a sleep-wake disorder is reserved for conditions identified with an objective sleep physiology study, or polysomnographic evidence. A polygraph machine records change in bioelectric potentials using electrodes placed on the skin of the scalp and face. An encephalogram (EEG) measurement of brain waves, an electro-oculogram (EOG) measurement of eye movements, and an electromyogram (EMG) measurement of muscle activity are recorded. Actigraphy is another innovative method for objective sleep monitoring that measures the sleeper’s activity during the night and day, but is unable to distinguish between true sleep and moments of motionless wakefulness.

Treatment of Sleep-Wake Disorders and Chronic Pain. Specific sleep disorders have specific treatments that can improve sleep for individuals with chronic pain. For example, continuous positive airway pressure (CPAP), use of a mouth appliance, decreased alcohol intake, and weight loss may be recommended for sleep apnea. A combination of adrenergic blocking agents, levodopa/carbidopa combinations, and benzodiazepines have been used for restless leg syndrome (RLS). However, the overall treatment approach to sleep in chronic pain is based on optimizing pain control, identifying and treating psychiatric comorbidity, carefully investigating sleep patterns, and use of sleep-specific pharmacotherapeutic and psychotherapeutic interventions for improving sleep.

Medications in general can be used mainly, or at least in part, for sleep, or are used chronically, and often show little ongoing benefit for sleep and cause significant side effects. Epidemiological studies show that U.S. patients with insomnia report sedative-hypnotic use ranging from 2.2% to 15%. Opioids have complex effects on sleep architecture, and are known to increase nocturnal movements and arousals, cause daytime somnolence, and are sedating, and users may develop tolerance over time. Traditional benzodiazepines, if being used for sleep rather than anxiety, should be discontinued due to their abuse potential and negative affect on sleep. If patients are being treated for comorbid depression, it is important to use sleep-friendly antidepressants (e.g., trazodone and mirtazapine) rather than SSRIs. Pain experts have also found that newer anticonvulsants (e.g., gabapentin) and atypical antipsychotics (e.g., quetiapine) may be useful for sleep.

When considering psychotherapeutic interventions for improving sleep, cognitive behavior therapy for insomnia (CBT-I) is widely regarded as one of the most effective treatments for insomnia. In addition, some of the CBT-I techniques are also independent treatments for insomnia that have strong research support, including:

• Sleep restriction therapy – Utilizes a form of systematic sleep limitation in which a sleep window is established and maintained to allow the body to relearn proper sleeping dynamics and increase sleep efficiency.

• Stimulus control therapy – Reduces the conditioned arousal individuals may experience when attempting to go to bed. Specifically, a set of instructions (going to bed only when sleepy; getting out of bed when unable to sleep; using the bed/bedroom only for sleep and sex; arising at the same time every morning; and avoiding naps) designed to reassociate the bed/ bedroom with sleep and to re-establish a consistent sleep schedule are implemented.

• Relaxation-based treatments – Teach formal exercises focused on reducing somatic tension (progressive muscle relaxation and autogenic training) or intrusive thoughts at bedtime (imagery training and meditation) and have been found to be equivocally effective. A 12-member National Institute of Health panel found general relaxation training helpful in chronic pain and insomnia.

Biofeedback is yet another modality that has modest research support for the treatment of insomnia. Biofeedback is a training technique delivered by a trained mental health professional that conveys information about a patients’ bodily functions that are typically considered outside conscious control. When treating insomnia, biofeedback is often used in conjunction with relaxation training or other behavioral approaches. Biofeedback has also shown to be effective for chronic pain management (Cosio, 2017d).

Bipolar and Related Disorders

The bipolar and related disorders include bipolar-I disorder, bipolar-II disorder, cyclothymic disorder, substance/medication-induced, due to another medical condition, and the “other specified” category. The defining feature of bipolar-I disorder is the presence of at least one lifetime manic episode. Mania is defined by the DSM as a distinct period of abnormally and persistently euphoric or irritable mood that lasts at least one week. Mood changes are accompanied by at least three of the following symptoms which lead to clear impairment: having overly confident self-esteem; having racing thoughts; being easily distractible; being excessively involved in pleasurable activities resulting in negative consequences; excessive talkativeness; decreased need for sleep; and increases in goal-directed activity. The manic episode must result in marked impairment in social or occupational functioning, or require hospitalization to prevent harm to self or others (such as financial losses, illegal activities, loss of employment, and self-injurious behavior). It is necessary to meet criteria for a manic episode to make a diagnosis of bipolar-I disorder, but it is not required to have hypomanic (a mild form of mania marked by elation and hyperactivity) or major depressive episodes. The other diagnoses under the bipolar and related disorders chapter differ from the bipolar-I diagnosis, such as:

• Bipolar-II disorder diverges in that it requires the lifetime experience of at least one episode of major depression and at least one hypomanic episode.

• Cyclothymic disorder is diagnosed when an individual experiences at least two years of both hypomanic and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression.

• Substance/medication-induced bipolar disorder is attributable to mania from the physiological effects of drug abuse (such as cocaine or amphetamine intoxication), or the side effects of medications or treatments (such as steroids, antidepressants, stimulants). However, a manic episode that arises during treatment (such as medications, electroconvulsive therapy, light therapy) or drug use, and which persists beyond the physiological effect of the inducing agent is sufficient evidence for a manic episode, the defining feature of bipolar-I disorder diagnosis.

• Other specified bipolar and related disorder category recognizes individuals, particularly children, who experience bipolar-like phenomena that do not meet the criteria for bipolar-I, bipolar-II, or cyclothymic disorders. However, if children exhibit recurrent silliness and “goofiness” beyond what is expected for their developmental level, have significant mood changes, attempt feats that are clearly dangerous and different from their normal behavior, and experience obvious and persistent increases in activity or energy levels, then a diagnosis of bipolar-I should be considered.

DSM-5-TR: In the new DSM-5, the chapter on bipolar and related disorders was placed between the schizophrenia spectrum and depressive disorders serving as a bridge. This “bridge” outlines how the new DSM-5 has moved away from a categorical to a dimensional approach. This decision was made due to its connection with psychosis and depression in terms of symptomatology, family history, and genetics. A few other details have been changed, including new mania criteria with an emphasis on changes in activity and energy, as well as, mood. In addition, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or to bipolar disorder when features of mania/hypomania are present. The DSM-5 also allows the specification of particular conditions for “other specified bipolar and related disorders.”

Bipolar and Related Disorders and Chronic Pain. Bipolar and related disorders are distinct from depression. The 12-month prevalence of bipolar-I disorder across eleven countries ranges anywhere from 0.0% to 0.6%, with the U.S. being the highest. Individuals diagnosed with bipolar-I disorder have high rates of serious and often untreated comorbid medical conditions. According to a recent meta-analysis, in people with bipolar disorder, the prevalence of clinical pain is approximately 29%; of migraine is about 14%; and of chronic pain is 24%. In fact, individuals diagnosed with bipolar disorder report almost four pain complaints at any one time. Musculoskeletal conditions, such as lower back pain, arthritis, and hip problems, have been found to be more prevalent among individuals with bipolar disorder then the general Department of Veteran Affairs’ patient population.

Migraines are one of the most common comorbid medical conditions diagnosed in individuals with bipolar disorder compared to the general population. The overall lifetime prevalence of migraine among bipolar disorders is 40%, and is 65% in a subgroup of individuals diagnosed with bipolar-II disorder. Migraines affect about one in seven persons (14%) diagnosed with bipolar disorder, who are three times more likely to experience migraines compared to the general population. Bipolar disorder and migraines are multifactorial in etiology; there appears to be vascular, cellular, molecular, neurochemical (serotonergic and noradrenergic), and genetic (KIAA0564) components in common between bipolar disorder and migraine conditions.

Individuals who suffer from pain and are diagnosed with a mental disorder, such as bipolar disorder, have been found to experience a worsening of psychiatric symptoms. In addition, healthcare professionals may at times fail to give complaints about physical health problems serious consideration among patients with serious mental illness. These patients are also less likely to recognize or monitor comorbid medical conditions compared to the general population. In addition, they have an increased likelihood of experiencing conditions that cause pain, and a lower probability of receiving adequate care. For example, people diagnosed with bipolar disorder have an increased prevalence of depression which has been linked to greater pain sensitivity. Chronic pain in persons diagnosed with bipolar disorder is associated with impaired recovery, greater functional incapacitation, lower quality of life, and increased risk for suicide compared to individuals without pain.

Assessing for Bipolar and Related Disorders.Due to informal or poor screening, the average time between onset of symptoms and formal diagnosis of bipolar disorder is more than seven years. Several semi-structured interviews have been developed to assess bipolar disorder in adults. The two most commonly used measures are the Structured Clinical Interview for DSM-IV (SCID) and the Schedule for Affective Disorders and Schizophrenia (SADS). The SCID and the SADS both provide interview probes, symptom thresholds, and information about exclusion criteria (such as medical or pharmacological conditions). The most reliable and valid way to obtain a diagnosis of bipolar disorder is through a structured interview with a trained mental health provider. However, several self-report measures have been developed to help identify persons most likely to meet criteria for bipolar disorders, such as the General Behavior Inventory and the Mood Disorder Questionnaire.

Treatment of Bipolar and Related Disorders and Chronic Pain. Individuals diagnosed with bipolar disorder who are treatment-adherent report statistically lower levels of pain than their non-treatment-adherent counterparts. Given these symptom patterns, there is a need for treatments that can provide mood stabilization in addition to the treatment of pain. Medications are recommended as the first line of treatment for bipolar disorder by a psychiatric provider. When treating more severe manic or mixed episodes, the initiation of either lithium plus an antipsychotic, or valproate plus an antipsychotic is recommended. For less-ill patients, monotherapy with lithium, valproate, or an antipsychotic may be sufficient. Monotherapy using an antidepressant is not recommended. A better understanding of the association of bipolar disorder and chronic pain can help limit adverse pharmacological side-effects. For example, a tri-cyclical antidepressant is often prescribed to treat chronic pain, but such medication (in the absence of a mood stabilizer) may trigger a manic episode in persons diagnosed with bipolar disorder. There is also evidence that suggests that non-steroidal anti-inflammatory drugs may increase serum lithium levels possibly eliciting lithium toxicity. In addition, analgesics, such as opioids, may alter mood, increasing the risk of eliciting a manic episode.

Psychological treatment research has focused mostly on outcomes for mania and depression separately. There is strong research support for psychoeducation and systematic care, and modest support for cognitive therapy (CT) for the treatment of mania, but psychoeducation and CT only have modest support as treatments for depression. Psychoeducation may be provided using the “Life Goals Program” manual to teach patients about their symptoms, the need for medications, and to provide support in achieving occupational and social goals. Participants also create personal self-management plans detailing coping strategies for early warning signs. Systematic care consists of a system-level intervention and a group therapy component, perhaps CT. At the system level, care for bipolar patents is provided by an outpatient specialty team comprised of a nurse care coordinator and a psychiatrist, with staff-patient ratios at a level that provides clients with regular appointments and easily available telephone consultations. All CT manuals include a psychoeducational component regarding the biological basis of the illness, the need for medications, and the early warning signs of symptoms. They also include a focus on identifying maladaptive, negative thoughts about the self, and teaching patients skills to challenge these overly negative thoughts. Many also include ideas about how to target the overly positive thoughts that might be present during mania.

There is strong research support for family-focused therapy (FFT) and modest support for interpersonal and social rhythm therapy (IPSRT), but FFT and IPSRT do not have research support for mania. FFT is a behaviorally-based intervention that includes psychoeducation, communication skills training, and problem-solving skills training. IPSRT builds upon the traditional focus of interpersonal psychotherapy by incorporating a behavioral self-monitoring program. The intention is to help patients diagnosed with bipolar disorder to initiate and maintain a lifestyle characterized by more regular sleep-wake cycles, meal times, and other cues given by the environment. The ultimate goal is to help regulate circadian disturbances that may provoke or exaggerate episodes of mood disorder. When the functional impairments of bipolar disorder are severe and persistent, other services may also be necessary, such as case management, assertive community treatment, psychosocial rehabilitation, and supported employment. These approaches, which have traditionally been studied in patients with schizophrenia, also show effectiveness for certain individuals diagnosed with bipolar disorder. Of course, we recommend physicians defer to a mental health professional for an accurate diagnosis and determination of appropriate treatment options (Cosio, 2017e).

Neurocognitive Disorders

There are an estimated 35 million people with dementia worldwide. This figure is expected to increase to 100 million by the year 2050. More compelling for pain practitioners is that the rate of dementia is known to rise with age to more than 50% in those 90 years of age or older, and the prevalence of chronic pain is 72% in those 85 years or older. The most common cause of dementia is Alzheimer’s disease, but dementia due to vascular, frontotemporal, and Lewy bodies are also prevalent. In all subtypes of dementia, specific neuropathological changes are responsible for the decline in function, cognition, and other symptoms, such as behavioral disturbances, psychological problems, and the breakdown of language and communication. Those with pain and dementia often express their pain through behavioral disturbances, such as agitation, screaming, and aggression.

The current DSM-5 chapter on Neurocognitive Disorders (NCD) begins with delirium, followed by the syndromes of major NCD (previously dementia) and mild NCD. The prevalence of delirium in the community is low (1%-2%) but increases with age, rising to 14% among individuals older than 85 years. Overall prevalence estimates for major NCD are approximately 1%-2% at age 65 years and as high as 30% by age 85 years. Estimates of the prevalence of mild NCD among older individuals are fairly variable, ranging from 2% to 10% at age 65 and 5% to 25% by age 85. The prevalence of mild NCD based on their etiological subtypes are as follows:

• Alzheimer’s disease ranges from about 60% to 90%, depending on the setting and diagnostic criteria.

• Vascular-related conditions range from 0.2% in the 65-70 years age group to 16% in individuals 80 years and older.

• Lewy bodies range from 0.1% to 5% of the general elderly population, and from 1.7% to 30.5% of all dementia cases.

• Parkinson’s disease steadily increases with age from approximately 0.5% between ages 65 and 69 to 3% at age 85 years and older.

• Conditions originating in the frontotemporal region are in the range of 2 to 10 per 100,000.

• Traumatic brain injury-associated disability is about 2% of the general population.

• HIV infection affects approximately one-third to over one-half of individuals, depending on the stage of the disease.

• Substance/medication-induced disorders are more likely to arise in those who are older and have a history of longer drug use, and/or have other risk factors such as nutritional deficits.

• Huntington’s disease in North America, Europe, and Australia is 5.7 per 100,000.

• The prevalence of prion disease is unknown.

Keep in mind that several of the NCDs frequently coexist in patients with dementia. The primary clinical deficit that these disorders have in common includes cognitive dysfunction that is acquired rather than developmental.

DSM-5-TR: The NCD were referred to in the DSM-IV as dementia, delirium, amnestic, and other cognitive disorders. The DSM-IV diagnoses of dementia and amnestic disorder are under the newly named major NCD, which is consistent with the rest of medicine and remains distinct to capture the care needs for this group. New to the DSM-5 is the less severe level of cognitive impairment, mild NCD, which in DSM-IV was subsumed under “cognitive disorder not otherwise specified.” Its presence is consistent with other fields of medicine, notably in Alzheimer’s disease, vascular disease, HIV infection, and traumatic brain injury-associated disability. In addition, distinct diagnostic criteria were added for major or mild NCD due to Lewy bodies, Parkinson’s disease, frontotemporal, traumatic brain injury, HIV infection, substance/medication-induced, Huntington’s disease, prion disease, multiple etiologies, and other medical conditions.

Neuropathological Changes in NCD Effect Pain. Current theory states that the areas of the brain involved in pain processing can be divided into two networks:

• The medial pain system – The pathway that mediates cognitive-evaluative and motivational-affective aspects of pain and is comprised of the amygdala, medial thalamus, hippocampus, anterior cortex cinguli, and prefrontal cortex.

• The lateral pain system – A pathway that mediates the sensory-discriminative aspects (localization, intensity, and quality of pain, which is comprised of the primary somato-sensoric areas and the lateral thalamic nuclei.

There may be an overlap between the two systems in the insula (the region of the brain that separates the frontal and parietal lobes from the temporal lobe).

There is conflicting evidence from neuropathological, neuroimaging, experimental, and clinical research regarding the impact of NCD on pain processing. However, support exists for decreased, unchanged, or increased pain processing in patients with dementia. In addition, there is speculation that atrophy of the gray matter may lead to an increase in pain tolerance, while white matter lesions appear to decrease pain tolerance. Thus, there still remains a great deal of uncertainty regarding the effects of neuropathological changes in NCD.

Neurocognitive Disorders and Chronic Pain. Scientific interest in the comorbidity of pain in NCD is relatively new. The literature indicates that the prevalence rate of patients with dementia that are regularly in pain varies from around 20% to higher than 50%. Evidence reflects that around 60% to 80% of individuals with NCD in dependent-care (nursing home) settings regularly experience pain, usually related to musculoskeletal, gastrointestinal, cardiac conditions, genitourinary infections, pressure ulcers in the skin, and/or orofacial pain. There have been few studies on pain in different subtypes of NCD, such as dementia due to vascular, frontotemporal, and Lewy bodies. Approximately 35% of stroke patients suffer from post-stroke central neuropathic pain, which also occurs in vascular dementia. The prevalence of some type of pain (musculoskeletal, dystonic, radicular-neuropathic, and central neuropathic pain) in Parkinson’s disease ranges from 68% to 85%. In terms of traumatic brain injury associated disabilities, the prevalence of chronic pain is about 52% among civilians and at least 42% among Veterans with comorbid post-traumatic stress disorder (PTSD) and persistent post-concussive symptoms.

Assessing for Neurocognitive Disorders. Musculoskeletal pain can be identified through gentle, guided movements. Self-reports of pain (visual analog, numeric rating, and faces pain scales) are possible in individuals with NCD depending on the patient’s memory, expectations, and capacity, but may become more challenging as neuropathological decline progresses. In cases of more advanced dementia, a proxy rater or a primary caregiver who is familiar with the patient’s usual behavior should be included in the pain assessment. Examples of caregiver rating scales are the Pain Assessment for the Dementing Elderly and the Pain Assessment Instrument in Noncommunicative Elderly.

The American Geriatrics Society published guidelines outlining the various behavioral expressions of pain in the elderly, including facial expressions, body movements, and vocalizations, which have been instrumental in the development of assessment tools for dementia. Examples of these tools include:

• Cohen-Mansfield Agitation Inventory;

• Discomfort Scale for Dementia of the Alzheimer’s Type;

• Checklist of Nonverbal Pain Indicators;

• Pain Assessment in Advanced Dementia;

• Facial Action Coding System;

• Observational Pain Behavior Assessment Instrument;

• Dementia Care Mapping;

• Elderly Pain Caring Assessment-2; and

• Behavioral Pathology in Alzheimer’s Disease Scale.

However, it has been suggested that instruments using observation and detection of pain related behavior may require further validation in people with NCD and assessment of their utility in clinical practice. The value of biomarkers of pain, particularly inflammation, should be considered as an enhancement of a pain assessment in patients with NCD.

Treatment of Neurocognitive Disorders and Chronic Pain. Healthcare providers are not sufficiently prepared to handle difficulties in establishing good pain management practice for patients with NCD. For example, the behavioral expression of pain in persons with NCD can be extremely distressing for both the patient and their caregiver, which can lead to inappropriate prescribing of antipsychotic medication instead of adequate pain treatment.

Providing a low dosage of pain medication seems to occur consistently in NCD patients in medical care, potentially due to the scarcity of pharmacological studies and the uncertainty in effective dosing with limited or no feedback from the patient. Thus, there is a need for this to be added to medical education in order to improve healthcare providers’ competency in distinguishing pain behaviors from other behavioral symptoms. Research has shown that verbal agitation (e.g., complaining, negativism, repetitious sentences and questions, constant request for attention, and/or cursing/verbal aggression) responds to pain treatment medication management of pain, while restlessness and pacing were sensitive to analgesics. The literature supports the value of stepped-care approaches of analgesia administration – from acetaminophen to opioids – to people with dementia. The consensus among experts is that a multidisciplinary approach to pain management, including pharmacological and non-pharmacological therapies, seems to offer the most benefit in relieving persistent pain among individuals with NCD despite there being no research data available to support such claims.

With regard to nonpharmacological options, there is a modicum of evidence that exercise and some complementary and integrative medical practices may be effective in lessening pain in some patients with NCD, such as:

• Moderate physical activity – Activity such as walking, has been shown to provide a double benefit in these patients by offering both pain relief and improved cognitive function

• Reflexology – The application of pressure to the feet and hands with specific hand techniques without the use of lubrication, has also provided some evidence of value in reducing pain experienced by individuals with NCD. The benefits of reflexology include cleansing the body of toxins, boosting the immune system, increasing circulation, promoting healing, and balancing energy

• Music therapy – A process by which music and all of its facets are employed to help patients improve their physical and mental health, has shown some promise. It appears that music therapy may be useful in providing a distraction from pain, promoting relaxation, and changing the patient’s attitude or improving mood. Music has been employed for procedural pain, postoperative pain, cancer pain, and arthritis pain. When engaged in music therapy, it is most effective when the music selection is based on patient preference. Its usefulness in patients with NCD can be enhanced when they are encouraged to tap out rhythm, sing, and dance, and the volume and length of the music intervention is in the patient’s control (Cosio, 2017f).

Obsessive-Compulsive and Related Disorders

Obsessive-compulsive and related disorders (OCD) is characterized by the presence of obsessions (recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted) and/or compulsions (repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession). OCD differs from developmentally normative preoccupations and rituals by being excessive or persisting beyond developmentally appropriate periods. While the specific content of obsessions and compulsions vary among individuals, certain symptoms are common in OCD, including those of cleaning, symmetry, forbidden or taboo thoughts, and harm. The inclusion of a chapter on obsessive-compulsive and related disorders in the new DSM-5 reflects the increasing evidence of these disorders’ relatedness to one another. The APA also moved OCD out of the chapter on anxiety disorders and put it into a new chapter. This reflects the recognition that OCD is its own disorder, while still maintaining a close relationship with anxiety disorders. The OCD chapter includes obsessive-compulsive, body dysmorphic, hoarding, trichotillomania, excoriation, substance/medication-induced, due to another medical condition, and other specified/unspecified OCD disorders.

The new chapter on OCD reflects the increasing evidence of these disorders’ relatedness to one another and distinction from other anxiety disorders. Creating unique diagnoses in DSM-5 was intended to increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for these conditions.Two new disorders have been added to the DSM-5 and to this chapter, including:

• Hoarding disorder – Reflects the persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Beyond the mental impact of the disorder, the accumulation of clutter can create a public health issue by completely filling people’s homes and creating fall and fire hazards. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.

• Excoriation disorder – Characterized by recurrent skin-picking resulting in medical issues such as infections, skin lesions, scarring, and physical disfigurement. Excoriation disorder has strong evidence for its diagnostic validity and clinical utility. Symptoms of these disorders cause clinically significant distress or impairment in social, occupational or other important areas of functioning including maintaining an environment for self and/or others.

DSM-5-TR: The disorders included in this new chapter have enough important differences between them to exist as distinct disorders. Some OCDs are characterized by cognitive symptoms, such as perceived defects or flaws in physical appearance as in body dysmorphic disorder or the perceived need to save possessions as in hoarding disorder. Other OCDs are characterized by recurrent body-focused repetitive behaviors, such as hair-pulling in trichotillomania and skin-picking in excoriation. Substance/medication-induced disorder consists of symptoms that are due to substance intoxication or withdrawal or to a medication. OCDs due to another medical condition involves symptoms characteristic of OCD that are the direct pathophysiological consequence of a medical disorder. Other specified/unspecified OCDs consist of symptoms that do not meet criteria for a specific disorder because of atypical presentation or uncertain etiology.

Does Chronic Pain Suppress OCD Symptoms? Initially, the notion was that obsessive-compulsive and related disorders were especially rare in pain patients, but there was no clear reason why this should be the case. What appears to be more likely is that a significant number of patients experience chronic pain that is composed of obsessions and compulsions that they try to suppress or neutralize. The obsessions may take the form of persistent, intrusive thoughts or images of pain. Although catastrophizing is not the same as intrusive thoughts, engagement in this behavior in chronic pain patients may provide some insight and support for this assertion. A number of case reports have detailed patients who overvalue their pain experience to the point of it being an obsession. Patients with complex regional pain syndrome, for example, may reveal bizarre perceptions, similar to a body dysmorphia, about a part of their body that they wish to amputate despite the prospect of further pain and functional loss. Chronic pain patients receiving adequate relief by opioids may also, for example, be hoarding opioid analgesics to ensure that he or she continues to receive adequate pain control by stockpiling reserves.

The compulsions consist of repetitive behaviors, such as rubbing, limping, guarding, or groaning, performed in response to the obsessive thoughts and images. Trichotillomania and excoriation, or skin-picking, are not self-harm but rather self-soothing behaviors. Both conditions fall under the body-focused repetitive behavior category, which is an umbrella term for impulse control behaviors involving compulsively damaging physical appearance or causing physical injury and at times added pain. Despite similarities, these cognitions and repetitive behaviors do not have the senseless or unrealistic quality of the classic symptoms of OCD. However, the psychological functions that these pain behaviors serve may be the same as those served by OCD. Sadly, patients with OCD who struggle to control obsessions in their lives may take comfort in the ability to control some component of aversive stimuli, such as exposure to physical pain. This, in turn, may lead to fear-avoidance behaviors. Pain anticipation and fear-avoidance beliefs significantly influence the behavior of patients with chronic pain in that they motivate avoidance behavior. Providers must be aware of the powerful effects of these cognitive processes.

OCD and Related Disorders and Chronic Pain. The 12-month prevalence of OCD in the U.S. is 1.2%. The prevalence of body dysmorphic disorder among U.S. adults is 2.4%. Nationally representative prevalence studies of hoarding disorder are not available. Community surveys estimate the prevalence of clinically significant hoarding in the U.S. to be about 2% to 6%. The 12-month prevalence estimate for trichotillomania in adults in the general population is 1% to 2%. The lifetime prevalence for excoriation disorder in adults in the general population is 1.4% or somewhat higher.

OCD is estimated to be the fourth most prevalent lifetime psychiatric disorder, but yet has gained less attention in chronic pain comorbidity research. The prevalence of OCD among treatment-seeking patients with mixed chronic pain conditions is about 1.1%. The prevalence of 12-month and lifetime OCD among patients with chronic pain is about 2% (with an onset before pain) and 2%, respectively. OCD typically has an onset in early adulthood and has a chronic nature, which may explain this result. Among patients with chronic, low back pain, the prevalence of OCD ranges from 2.0% to 8.2%, with a lifetime prevalence of 13.4%. The prevalence of OCD among patients with chronic, musculoskeletal pain was 0.0%, whereas the lifetime prevalence of OCD in treatment seeking multiple sclerosis patients was found to be 8.6%.

Assessing for OCD. There are several different assessment measures composed of items measuring specific and typical types of obsessions and compulsions currently available, such as the Obsessive Compulsive Inventory-Revised, the Padua Inventory-Revised, the Vancouver Obsessive Compulsive Inventory, and the Schedule of Obsessions, Compulsions, and Pathological Impulses. There are other measures which first identify the respondent’s most salient obsessions and compulsions and then rate these symptoms on multiple parameters of severity (time occupied/frequency, interference in functioning, associated distress, degree of resistance, and perceived control), such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Dimensional Y-BOCS. The Y-BOCS includes a checklist of more than 60 specific types of obsessions and compulsions that the respondent could indicate as present or absent, while the Dimensional Y-BOCS includes a checklist of more than 100 items.

Treatment of OCD and Related Disorders and Chronic Pain. Some scholars have suggested that OCD is the most challenging of the traditionally defined anxiety disorders (DSM-IV) to treat. Research has shown that even cases that have subthreshold symptoms and do not have OCD diagnosed are associated with poorer self-reported physical health. The cognitive and social rigidity associated with the obsessive-compulsive and related disorders can influence pain behavior which will have an impact in the treatment process. Patients with chronic pain may require a treatment plan that particularly encourages and supports the patients to verbalize their pain-related fears and disabilities.

In terms of psychotherapy, there is moderate-strong research support for several interventions, including:

• Exposure and response prevention – Based on the premise that if individuals confront their fears and discontinue their escape response, they will eventually reduce their anxiety. Exposure and response prevention instructs individuals with OCD to repeatedly confront the thoughts, images, objects, and situations that make them anxious and/or start their obsessions in a systematic fashion, without performing compulsive behaviors that typically serve to reduce anxiety. Through this process, the individual learns that there is nothing to fear and the obsessions no longer cause distress.

• Cognitive therapy (CT) – Proposes that persons susceptible to anxiety develop inaccurate/unhelpful core beliefs about themselves, others, and the world as a result of their learning histories. These beliefs can be dormant for extended periods of time and are activated by life events that carry specific meaning for that person. CT also focuses on information processing deficits, selective attention, and memory biases toward the negative. In CT, patients are taught cognitive skills so they can develop more accurate/ helpful beliefs and eventually become independent.

• Acceptance and commitment therapy (ACT) – Behavioral therapy that is based on Relational Frame Theory, a theory of how human language influences experience and behavior. ACT aims to change the relationship individuals have with their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Acceptance and mindfulness strategies are used to teach patients to decrease avoidance and attachment to cognitions, and increase focus on the present. Patients learn to clarify their goals and values and to commit to behavioral change strategies.

There are other psychological treatments that may also be effective in treating OCD, but they have not been evaluated with the same scientific rigor as the treatments aforementioned. There is some evidence that Anafranil, a tricyclic antidepressant, may have specific anti-obsessional effects. If the experience of chronic pain does, in fact, share essential similarity with OCD, then this anti-depressant may be of particular value in the treatment of OCD in chronic pain patients. Providers are recommended to seek consultation with a mental health professional for an accurate diagnosis and discussion of various treatment options for OCD (Cosio, 2017g).

Dissociative Disorders

According to the DSM-5, dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior which can potentially disrupt every area of psychological functioning. The dissociative disorders include dissociative identity disorder (DID), dissociative amnesia, depersonalization/derealization, other specified, and unspecified dissociative disorders. Individuals with DID experience recurrent, inexplicable intrusions into their conscious functioning and sense of self, alterations of sense of self, odd changes of perception, and intermittent functional neurological symptoms. Only about 6% of people with DID present their “multiple” or “dissociated identities” publicly and obviously.

Unlike depictions in sensationalistic movies, such as Sybil and Split, most people with DID do not have dramatic shifts in personality and only persons very close to them are aware of mood swings. Dissociative amnesia is fundamentally an inability to recall autobiographical information that is inconsistent with normal forgetting, and it may involve bewildered wandering, or a fugue. Depersonalization/derealization disorder is characterized by clinically significant persistent or recurrent detachment from one’s mind, self, or body and/or detachment from one’s surroundings. These alterations of experience are accompanied by intact reality-testing. The residual categories of other specified and unspecified dissociative disorders fall short of the diagnostic criteria for the other dissociative disorders.

Stress often produces transient exacerbation of dissociative symptoms that makes them more evident. In fact, dissociative disorders are frequently found in the aftermath of severe trauma, including persistent psychological, physical, or sexual abuse during childhood. Thus, the dissociative disorders chapter is placed next to the trauma- and stressor-related disorders in DSM-5, reflecting the close relationship between these diagnostic classes.

DSM-5-TR: Several changes have been made to the criteria for dissociative disorders in DSM-5. First, the criteria for DID has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. The criteria for DID also now specifically states that transitions in identity may be observable by others or self-reported, and the individual may have recurrent gaps in recall for everyday events, not just for traumatic experiences. The DSM-IV diagnosis of dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis. Derealization is now included in the name and symptom structure of what previously was called depersonalization disorder in DSM-IV.

Alters Can Report Different Pain Levels. There is research that indicates that subjects who report more dissociative experiences have higher pain thresholds. There have been reports which suggest that different personalities “take over” at times of more severe pain. For example, patients with dissociative disorders frequently report amnesia for self-injury. Perhaps, the patient has learned voluntarily to induce the altered states of consciousness, or the “switching” process, whereby different personalities assume executive control, or to “be out.” These alters may present as having different ages, gender, characteristics, and levels of awareness of their autobiography. Some will be aware of, or be “co-conscious with,” other parts of the personality. Therefore, the predominant or primary personality in cases of DID is often designated as the “host personality.” A study done in 1993 documented a difference in pain perception, location, and estimates of secondary functional impairment between four different personalities in the same patient. Bear in mind, these alters are not actually separate identities, but rather parts of a single individual that are not yet functioning together in a smooth, coordinated, and flexible way.

Dissociative Disorders and Chronic Pain. The 12-month prevalence of dissociative identity disorder among adults in a U.S. community was 1.5%; for dissociative amnesia was 1.8%; and the lifetime prevalence for depersonalization/ derealization disorder is approximately 2%. The prevalence of dissociative disorders in clinical settings ranges between 5% and 20.7% among inpatients; between 12% and 38% among outpatients; and 34.9% among patients presenting to a psychiatric emergency room. The research looking at the incidence of chronic pain among individuals with dissociative disorder is scarce. In an extensive review of 52 previously reported cases of DID (previously called multiple personality disorder), headaches was the most frequent somatic complaint occurring in more than 60% of subjects. Saxe and colleagues (1994) also found that somatic symptoms such as headaches, joint pain, back pain, pelvic pain, and pain in extremities were more common in patients with dissociative disorders than in controls.

Assessing for Dissociative Disorders. DID is often difficult to detect due to the hidden nature of the dissociative symptoms, the coexistence of other mental health disorders, and feelings of disconnection that are often difficult to verbalize. Before the development of specialized diagnostic tests, people suffering from dissociative disorders were misdiagnosed for many years, preventing the start of effective treatment. Studies indicate that previous diagnoses (bipolar, depression, anxiety, psychotic, and/or substance abuse disorders) are common to people with DID, and it is not uncommon for a decade or more to pass before a correct assessment of DID is made. Over the past 25 years, there has been an increase in scientific research on the diagnosis and treatment of dissociative disorders. Screening tools such as the Dissociative Experience Scale and the Somatoform Dissociation Questionnaire, and diagnostic tools such as the Structured Clinical Interview for Dissociative Disorders, “the gold standard,” have helped advance work in the identification and treatment of these disorders. Screening tests cannot diagnose people with a dissociative disorder but can help identify people who have dissociative symptoms and need to be evaluated further. Thus, it is recommended that providers seek out a specialized evaluation with a trained mental health professional.

Treatment of Dissociative Disorders and Chronic Pain. Patients with dissociative disorders often have complex presentations with high levels of comorbid psychiatric difficulties, are taking multiple psychotropic medications, and are almost always excluded from research. As a result, information about treatment outcomes with dissociative disorder patients is limited. The treatment of dissociative disorders is specialized psychotherapy, which focuses on understanding the dissociative symptoms and developing new constructive ways of coping with stress. The dissociation may be acting as a creative survival mechanism in the face of overwhelming trauma, whereby the mind shields itself by segregating the experience, or “splitting” it off into its constituent parts rather than experiencing it as what would be an unendurable “whole."

Though DID is the most severe of the dissociative disorders, it responds well to long-term psychotherapy intended to help the patient merge his/her multiple personalities into one personality. The trauma of the past has to be explored and resolved with proper emotional expression. The consensus of experts is that phase-oriented treatment is most effective. The three stages most commonly used are:

1. Establishing safety, stabilization and symptoms reduction;

2. Working through and integrating traumatic memories; and

3. Integration and rehabilitation.

Hospitalization may be required if behavior becomes bizarre or destructive. Patients in later stages of treatment have been found to engage in fewer self-injurious behaviors, fewer hospitalizations, and showed higher levels of adaptive coping than those in the initial stages. Additionally, patients in the later stages of treatment tend to report lower symptoms of dissociation and distress than patients in the initial stages of treatment.

Medications (antidepressants, anticonvulsants, or tranquilizers) can be used as an adjunct to psychotherapy, but is not the primary form of treatment. These medications help control the mental health symptoms associated with the disorders, but there are no medications that specifically treat dissociative disorders.

When treating dissociative amnesia (including dissociative fugue), psychotherapy often involves hypnosis (helps patients remember and work through trauma); creative art therapy (helps a person express his/her thoughts); cognitive behavioral therapy (CBT) (helps identify unhealthy and negative beliefs/behaviors); and medications (Pentothal). Patients with dissociative disorders are most frequently found to be highly hypnotizable in comparison to patients diagnosed with other mental health disorders. Treatment for depersonalization disorder is very difficult. However, the condition can improve with a thorough therapeutic exploration of the trauma in the individual’s past and the use of eye-movement desensitization and reprocessing (EMDR). EMDR is designed to alleviate the distress associated with traumatic memories, and combines the CBT techniques of re-learning thought patterns with visual stimulation exercises to access traumatic memories and replace the associated negative beliefs with positive ones. Thus, it is recommended that providers seek out a specialized treatment with a trained mental health professional (Cosio, 2017h).

Anger Expression and Disruptive, Impulse Control, and Conduct Disorders

Where there is pain, there is an unpleasant affect which may include anger. Anger refers to an emotional experience which can be a current mood state or a general predisposition toward feeling angry. Anger as a trait is more common in aggression and studied in health outcome research. Anger is a natural emotion that helps us feel more in control. Relative to other negative emotions, such as fear, sadness, guilt, and shame, anger is the most prominent emotion in chronic pain patients. It is related to how we think about an event, person, or situation. It is important to also remember that anger does not occur in a vacuum, but has far-reaching effects on occupational, recreational, social, interpersonal, and self-care functions. There are several signs of uncontrolled anger, including:

• having a short temper/being inpatient;

• sleep problems;

• eating problems;

• restlessness/agitation;

• hitting things/slamming things;

• having a desire to harm someone;

• verbal outbursts;

• feeling like you’re losing control of your life;

• poor concentration;

• obsessing about the event, person, or situation;

• having negative affects to physical health; and

• increasing pain.

Anger has been linked to inflammation, particularly with blood levels of c-reactive protein and interleukin-6. Anger may function as a predisposing factor, but can also be a precipitant, an exacerbation, a consequence, and a perpetuating factor in pain. There are many challenges that people with chronic pain face, including diagnostic ambiguity, treatment failure, battles with insurance carriers, employers, and the legal system. Pain and suffering are diverse and can take the form of anger, which, if left unaddressed, could then be drawn out into disruptive, impulse-control, and conduct disorders.

Disruptive, impulse-control, and conduct disorders include conditions involving problems in the self-control of emotions and behaviors. While other disorders in DSM-5 may also involve problems in emotional and/or behavioral regulation, the conditions in the disruptive, impulse-control, and conduct disorders chapter are unique in that these problems are manifested in behaviors that violate the rights of others. These behaviors then bring the individual into significant conflict with societal norms or authority figures. The underlying causes of the problems in the self-control of emotions (such as anger) and behaviors (such as aggression) can vary greatly across the disorders. The disruptive, impulse-control, and conduct disorders include diagnoses, such as oppositional defiant disorder, intermittent explosive disorder, conduct disorder, pyromania (fire-setting), kleptomania (stealing), and antisocial personality disorder (which also falls under the personality disorders). These conditions are a major public health problem because they greatly increase the risk of incarceration, injury, depression, substance abuse, and death by homicide or suicide.

DSM-5-TR: The chapter on disruptive, impulse-control, and conduct disorders is new to DSM-5. It brings together disorders that were previously included in other chapters focusing on adolescence and impulse-control in the DSM-IV. Several additional changes have been made to the specific diagnoses. The symptoms of oppositional defiant disorder are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The primary change in intermittent explosive disorder is that the types of aggressive outbursts now include physical aggression, verbal aggression, and nondestructive/non-injurious aggression. The criteria for conduct disorder, pyromania, and kleptomania are largely unchanged from DSM-IV. Antisocial personality disorder is also present in this chapter in addition to the chapter on personality disorders in the DSM-5.

Frontline Providers are at Risk for Patient-Perpetrated Violence. There is evidence to suggest that frontline providers may be at risk for patient perpetuated violence. The U.S. Bureau of Labor Statistics report that more workplace assaults and violent acts occur in health care and social service industries than in any other. In one decade, about 30 physicians in the U.S. were the victims of work-related homicides. One study found that 63% of physicians queried indicated that they had experienced abuse or violence during the previous year, and 11% reported verbal abuse daily. The most common reasons for the violence are:

• drug-seeking behaviors and confrontations over the issue;

• long waits for service in physician offices;

• dissatisfaction or displeasure with care or outcomes;

• relationship with religion or God; and

• the physician’s refusal to endorse a report of disability.

The risk factors most consistently associated with this violence includes past antisocial conduct, past violence, history of opioid abuse, and poor impulse control.

Disruptive, Impulse Control and Conduct Disorders and Chronic Pain. The disorders in this chapter tend to have first onset in childhood or adolescence. The prevalence of oppositional defiant disorder ranges from 1% to 11%. The one-year prevalence data for intermittent explosive disorder in the U.S. is about 4% to 7%. The one-year population prevalence estimates for conduct disorder range from 2% to 10%. The lifetime prevalence of fire-setting was reported as 1% in a population sample. The prevalence of kleptomania in the general population is approximately 0.3% to 0.6%. Approximately 5% to 15% of the U.S. population are experiencing, and disabled by, impulse control disorders.

Research on anger in relation to pain has been recent in history and slow to accumulate. This may be due in part to anger not being a diagnostic category in psychiatric nosology. Approximately 70% of chronic pain patients have reported having angry feelings toward themselves and health care professionals, but this may be an underestimation. Among people with chronic pain, high levels of anger are associated with greater muscle tension, pain severity, and pain behaviors. In a sample of chronic pain patients undergoing an extensive psychiatric evaluation, about 10% met criteria for intermittent explosive disorder. Research has shown that intermittent explosive disorder is associated with arthritis, back/neck pain, headaches, and other chronic pain conditions. Past research has shown that individuals with migraines or tension headaches have higher anger levels and poorer anger control. Findings also suggest that anger management style is a particularly important predictor of treatment outcomes in male chronic back pain patients. Results indicate that patients who scored high on hostility had significantly higher ratings of chest pain. Earlier research also found that anger was an important predictor of pain in patients suffering from spinal cord injuries. In cancer pain, the research shows that the level of anger was significantly higher in patients having pain versus no pain, and those experiencing pain had higher intensity and longer duration of anger.

Assessing for Risk of Violence. The first step in a clinical examination for the assessment of violent behavior is to establish how many of these risk factors may be present. There are also clues that physicians may look for that suggest imminent violent behavior, including:

• being demanding;

• irritability;

• flared nostrils;

• boisterousness;

• clenched fists;

• loud talking;

• yelling;

• threats;

• abusive or profane language;

• restless or repetitive movement;

• pacing;

• gesticulating; and

• attacks on objects.

If any of these are noted, then the physician and his/her staff should initiate measures to ensure their safety rather than allow the situation to escalate further. Providers may also choose to use self-report instruments to measure anger, such as the Profile of Mood States, the Clinical Anger Scale, the Subjective Anger Scale, the Multidimensional Anger Inventory, and the State-Trait Anger Expression Inventory-2. Thus, medical providers need to screen for patients who suffer from pain and anger, and facilitate a referral to a mental health professional for additional assessment if needed.

The physician should create space between themselves and the angry patient, and engage in other behaviors that may calm the situation. Providers should not argue with the patient, and should avoid provocation. They need to remain calm and not get angry. It is helpful if providers communicate in a calm, supportive manner, and do not talk down to the patient. It is important that providers do not show fear, and do not touch the patient. Providers can help by determining what the patient is angry about, and trying to rectify the situation. They may want to consider calling 911 for assistance if they are unable to deescalate the situation. Pain physicians should expect to come into contact with these types of patients and be prepared to deal with these situations if necessary.

Treatment for Anger. Anger that is unmanaged can complicate pain management efforts by disrupting relationships with healthcare providers and may interfere with medical or surgical procedures for chronic pain. This underlines the importance of the therapeutic relationship. The therapeutic relationship, or therapeutic alliance, is a common factor in psychotherapy identified by Grencavage and Norcross. Therapeutic relationship factors are characteristics of the provider and the patient that facilitate change and are present regardless of the type of intervention. Past research has shown that the therapeutic relationship accounted for 30% of treatment outcome. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings.

There are also many therapeutic strategies available to be considered to help deal with anger. A predominant model of the etiology of chronic pain hypothesizes that feelings of intense anger that are repressed or unexpressed are likely to manifest as pain.

One of the most common types of psychotherapy available to treat anger is cognitive behavioral therapy (CBT). The purpose of CBT for anger is to help a person recognize the self-defeating negative thoughts that lie behind anger flare-ups. Patients learn to cope better with difficult life situations, positively resolve conflicts in relationships, deal with grief more effectively, mentally handle emotional stress, and overcome chronic pain. There are other CBT therapies that include anger management protocols and dialectical behavioral therapy (DBT). Patients learn how to deal with their particular issues using conscious, goal-centered strategies:

1. Help the patient develop awareness. They will learn how to identify environmental and internal/external triggers, be aware of how their body reacts to anger, and how they usually behave when they are angry. They also learn how to identify underlying thoughts and feelings (fear, guilt, grief, confusion, shame, loss, etc.).

2. Modify their response to anger. Patients can learn how to use relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation. They also can learn how to change the way they think using cognitive restructuring. Patients can benefit from learning how to change their behaviors. Specifically, they may learn how to focus on problem-solving, look for an outlet (exercise, hobby, talking to someone, etc.), distract themselves (such as by going to the movies with a friend), and/or learn healthier alternatives, such as using humor.

3. Help patients learn the difference between passive, passive-aggressive, aggressive, and assertive communication, and provide ways to improve messaging. Patients learn how to express angry feelings in an assertive manner, which is the healthiest way, while still respecting the rights of others. To do this, they have to learn how to make clear what their needs are and how to get them met without hurting others. They learn that being assertive doesn’t mean being pushy or demanding, but rather it is being respectful of themselves and others.

It is also possible to treat anger symptoms with medication. Antidepressants are commonly prescribed because they have a calming effect, but these medications do not specifically target anger. The purpose of medications is to complement the psychotherapeutic process, not to replace or complicate it. There are also a number of herbs and supplements that have shown some promise in improving mood and supporting anger management therapy, including valerian and chamomile. Medical providers need to screen their patients who suffer from pain for anger, and facilitate a referral to a mental health professional for treatment if needed (Cosio, 2018d).

Chronic Pain and Polarizing Topics

Despite numerous studies documenting a strong association between chronic pain and psychopathology, there is still scant research for certain mental health categories, such as:

• neurodevelopmental;

• feeding and eating;

• elimination;

• sexual dysfunction;

• gender dysphoric;

• paraphilic; and

• “process” or behavioral addictive disorders.

Some of these mental conditions are less polarizing, or “taboo,” than they were in the past and some are more than ever. While most taboos have to do with sex, some have to do with food and other beliefs. Even though these disorders seem very different, what they all have in common is that they may bring discomfort to people when discussed. They also share a lack of information available about their relationship to chronic pain. The following is a summary describing these disorders, their relationship with pain, and the available treatments for each condition.

The first step in addressing any of these conditions is to ask open-ended questions. Frontline providers often steer away from addressing these conditions because it is difficult to find the balance between sensitivity and truth when speaking about often-polarizing, or “taboo” topics. Providers will best be able to address concerns related to these topics if they listen without judgment, express empathy, be concise, and make sure they watch their body language when addressing these topics.

Neurodevelopmental Disorders

These disorders include intellectual developmental disorder, communication, autism spectrum, attention deficit hyperactive, motor disorders, and specific learning disorders. Communication disorders include language, speech sound, childhood-onset fluency (stuttering), and social (pragmatic) communication disorders. Autism spectrum disorder encompasses autism, Asperger’s, childhood disintegrative, and pervasive developmental disorders, and is characterized by deficits in social communication and social interaction, and restricted repetitive behaviors, interests, and activities. Motor disorders include developmental coordination, stereotypic movement, Tourette’s, persistent (chronic) motor or vocal tic, provisional tic, and other tic disorders. Specific learning disorders combine reading (dyslexia), mathematics (dyscalculia), written expression, etc.

DSM-5-TR: Diagnostic criteria for intellectual developmental disorder (previously mental retardation and intellectual disability) include the deficits in cognitive capacity beginning in the developmental period. Attention-Deficit/Hyperactivity Disorder (ADHD) essentially remains the same except it was placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates.

Neurodevelopmental Disorders and Chronic Pain. A study in 2011 found that chronic pain is a significant problem for persons with intellectual developmental disorder. Caregivers reported that 15.4% of their sample was experiencing chronic pain for an average of 6.3 years. Significantly more females than males reported pain, although age, communication ability, and level of intellectual developmental disorder were not found to be associated with pain. The presence of pain was associated with cerebral palsy, physical disability, and reports of challenging behavior. The prevalence rates for persons with intellectual developmental disorder is approximately 1%, but vary by age; autism spectrum disorder occurs in about 2.5% of adults; and the rate of ADHD appears to be approximately 4%; but the rate of specific learning disorders is unknown across academic domains in adults.

Treatment for Neurodevelopmental Disorders and Chronic Pain. Supportive services are the most common treatments for people with neurodevelopmental disorders. These services may include behavioral therapy, education, speech therapy, physical or occupational therapy, and family or supportive counseling. When it comes to ADHD, the strongest research support is for cognitive behavioral therapy (CBT).

Feeding and Eating Disorders

These disorders include pica, rumination, avoidant/restrictive food intake, anorexia nervosa, bulimia nervosa, and binge-eating disorders. Pica and rumination disorder have been revised for clarity and to indicate that the diagnoses can be made for individuals of any age. Avoidant/restrictive food intake disorder is a broad category intended to capture those who substantially restrict their food intake and experience significant associated physiological or psychosocial problems but do not meet criteria for other eating disorders. Anorexia nervosa has remained conceptually unchanged and the person must still be at a significantly low body weight for their developmental stage. Bulimia nervosa also remains unchanged and the person must engage in binge eating and inappropriate compensatory behavior once weekly. Binge-eating disorder requires that the person engage in a minimum average frequency of binge eating at least once weekly over the past three months.

Feeding and Eating Disorders and Chronic Pain. Lifetime bulimia nervosa and binge eating disorders have significant associations with numerous physical conditions. The odds of bulimia nervosa and binge eating disorder predicting musculoskeletal pain (1.6%-2.8%) and other pain conditions (1.9%-2.8%) are generally comparable. The prevalence of pica is unclear; for rumination disorder the prevalence data is inconclusive; for anorexia nervosa, the 12-month prevalence among females is approximately 0.4% and has a 10:1 female-to-male ratio; for bulimia nervosa, the 12-month prevalence among females is 1%-1.5% and has a 10:1 female-to-male ratio; and for binge eating disorder, the 12-month prevalence among females and males is 1.6% and 0.8%, respectively.

Treatment for Feeding and Eating Disorders and Chronic Pain. A treatment plan for feeding and eating disorders may include psychotherapy, nutrition education, medications (e.g., antidepressants), hospitalization or day programs, and ongoing treatment for other health problems (e.g., dental, bone density, menstruation). When it comes to anorexia nervosa, there is modest but controversial research support for CBT. On the other hand, bulimia nervosa and binge-eating disorders have strong research support for CBT and interpersonal psychotherapy, but bulimia nervosa has modest support for family-based treatment.

Elimination Disorders

These disorders include enuresis and encopresis. These disorders essentially remain unchanged from previous DSM versions. According to a study in 2001, the most frequent problem in urologic practice is recurrent or chronic genital pain with no physical cause. Despite the frequency of the problem, very little has been written about this condition and treatment is generally ineffective. In 2012, another study found that 2/3 of adolescents with a high pain dysfunctional profile would later develop a pain-related gastrointestinal disorder at follow-up. These adolescents were characterized by low perceived pain coping efficacy and high levels of negative affect, pain catastrophizing, and functional disability.

Elimination Disorders and Chronic Pain.The prevalence of enuresis is around 1% among individuals 15 years or older; and encopresis is prevalent among approximately 1% of 5-year-olds.

Treatment for Elimination Disorders and Chronic Pain.The most common treatments for elimination disorders include behavioral therapy, reward systems (e.g., moisture alarms and sensors), dietary changes, and/or pharmacological options.

Sexual Dysfunctions

These disorders include delayed ejaculation, erectile, female orgasmic, female sexual interest/arousal, genito-pelvic pain/penetration, male hypoactive sexual desire, premature ejaculation, and substance/medication-induced disorders. Sexual dysfunctions are referred to as sexual pain or to a disturbance in one or more phases of the sexual response cycle. These disorders now require a minimum duration of approximately six months and more precise severity criteria.

DSM-5-TR: Genito-pelvic pain/penetration disorder is new in DSM-5 and represents a merging of vaginismus and dyspareunia, which were highly comorbid and difficult to distinguish.

Sexual Dysfunctions and Chronic Pain. In a 2001 study, 73% of respondents had pain-related difficulty with sexual activity. There were few differences between men and women. Most of the respondents had several difficulties and in various combinations, including arousal, positioning, performance, and relationship issues. All except positioning were associated with less frequent sexual activity. Another study found that sexual dysfunction is predicted by psychological factors and pain duration, but other issues have more of a significant impact on quality of life. The prevalence of delayed ejaculation is unclear because of the lack of a precise definition; for erectile disorder, about 13% to 21% of men 40-80 years-of-age complain of occasional problems; for female orgasmic disorder, the prevalence rates vary from 10% to 42%; for female sexual interest/arousal disorder, the prevalence as defined in the DSM-5 manual is unknown; for genito-pelvic pain/penetration disorder, approximately 15% of women report recurrent pain during intercourse; for male hypoactive sexual desire disorder, the lack of interest lasting six months or more affects 1.8% of men ages 16-44; for premature ejaculation, 20%-30% of men ages 18-70-years-of-age report occurrence; and for substance/medication-induced disorder, there are elevated rates reported with methadone or high-dose opioid drugs for pain and is higher in individuals who abuse heroin (approximately 60%-70%).

Treatment for Sexual Dysfunctions and Chronic Pain. Different services may be offered to address sexual dysfunction, including sex education, coaching; sensate focus (discovering erogenous zones through non-genital stimulation); vacuum devices and intracavernosal injections; and pharmacological agents and herbs.

Gender Dysphoria

Gender dysphoria (gender identity disorder) is considered to be a multicategory concept rather than a dichotomy. A post-transition specifier has been added because many individuals after transition no longer meet criteria for gender dysphoria.

Gender Dysphoria and Chronic Pain. Chronic pain has been found to have a negative impact on an individual’s gender identity, or their subjective sense of being a man or a woman. In a 2010 study, both laypeople and nurses perceived men with chronic pain as less masculine and more feminine; women with chronic pain as more masculine and less feminine; and the men and women with chronic pain were more similar to each other than other men/women. When it comes to transgender and/or gender nonbinary people, we do witness an increase in pain especially in the areas of the body that change as a result of cross-sex hormone treatment. One study in 2007 found that about 30% of MTF subjects reported headaches, breast, and musculoskeletal pain. About 62% of FTM subjects reported pain that improved after testosterone administration. When in reference to prevalence rates for gender dysphoria, sex ratios favor gender dysphoria natal males, with ratios ranging from 1:1 to 6.1:1.

Treatment for Gender Dysphoria and Chronic Pain. To be clear, gender dysphoria is neither a sexual dysfunction nor a paraphilia. It is treated with a combination of psychotherapy, hormone therapy, social gender role transition, and/or surgery.

Paraphilic Disorders

These disorders include voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorders. Paraphilias (e.g., an erotic focus on a person or a sexual act) are not in themselves mental disorders. There is a distinction between paraphilias and “paraphilic disorders.” A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual, or a paraphilia whose satisfaction has entailed personal harm or risk of harm to others. The DSM-5 does not automatically label nonnormative sexual behavior as psychopathological.

Paraphilic Disorders and Chronic Pain. Information about the relationship between paraphilic disorders and chronic pain is lacking. In regard to paraphilias, it is estimated that 29% of men with pain were not able to fantasize about a sexually attractive person; erotic parts of a woman’s body; erotic or romantic situations; caressing, touching, undressing, or foreplay; and/or sexual intercourse, oral sex, touching to orgasm. The lifetime prevalence rates for voyeuristic disorder is approximately 12% in males and 4% in females; for exhibitionistic disorder, the prevalence in males is 2%-4%; for frotteuristic disorder, it is 30% of adult males in the general population; for sexual masochism disorder, it is 2.2% of males and 1.3% of females in the past 12 months in Australia; for sexual sadism disorder, the prevalence varies from 2% to 30%; for pedophilic disorders, the highest possible prevalence in males is 3%-5%; there is no data available for fetishistic disorder; and for transvestic disorder, the prevalence is fewer than 3% of males.

Treatment for Paraphilic Disorders and Chronic Pain. The treatment for paraphilic disorders may include psychotherapy, pharmacology, and/or surgical intervention (e.g., castration due to pedophilia seen in prisons).

Process or Addictive Disorders

There are two current disorders in the DSM-5 which are considered “process” addictive disorders, including gambling disorder (found in the substance use and addictive disorder chapter) and internet gaming disorder (found in the under conditions for further study chapter). However, there are others that are found in the literature, such as video game, food, shopping/spending, exercise, and sex addictions. There is some evidence that these behaviors activate the brain reward system with effects similar to those of substance use. Little has been documented regarding problematic internet usage. Some addiction recovery institutions began treating those suffering from internet addiction after seeing the power of screening for other process addictions, especially gambling.

Process or Addictive Disorders and Chronic Pain. The lifetime prevalence rate for gambling disorder is about 0.4% to 1.0%. The highest prevalence rate for internet gambling disorder is in male adolescents 12-20 years of age (still under conditions for further study). There is no data available about the other process or addictive disorders, such as video game, food, shopping/spending, exercise, and sex addictions.

Treatment for Process or Addictive Disorders and Chronic Pain. As with gambling addiction, internet gaming addiction is a clinical impulse control disorder. Both disorders are addressed with psychotherapy, medications, and self-help groups. Twelve-step programs may also be utilized, such as gamblers anonymous and online gamers anonymous (Cosio, 2018e).

Evidence-based Psychological Interventions

Classification System

The relevance of psychotherapy in chronic pain management is not questioned anymore thanks to the investigations of the social and psychological components of pain. In 2007, a classification of psychological techniques was developed based on which component of pain is the focus of treatment, including sensory, affective, cognitive, and behavioral.

Sensory Component: Modifying the Emotional and Cognitive Meaning

Treatments that focus on the sensory component mainly aim to attain a change in the sensation of pain by modifying its emotional and cognitive meaning. There are several psychological techniques that fall under this category, including:

• Guided imagery – A therapeutic technique in which a facilitator uses descriptive language intended to psychologically benefit mental imagery. Guided imagery is using your imagination to create sensory images that decrease your pain. This often involves several or all of the senses in the mind of the listener, including vision, smell, sounds, touch, and taste. The length is tailored to the patient’s preference and energy level. Oftentimes, guided imagery sessions can use an audiotaped script or a live guide. Caution is given for this technique to be used in patients with dissociative disorders. Research has found evidence of a positive effect on arthritis or rheumatic diseases, and potential positive effects on the secondary outcomes of anxiety, mobility, and quality of life. However, patients with fibromyalgia experienced no effect on pain with guided imagery, but potential positive effects on secondary outcomes including psychological distress and coping with pain.

• Hypnosis – A procedure involving cognitive processes, such as imagination, in which a patient is guided by a health professional to respond to suggestions for changes in perceptions, sensations, thoughts, feelings, and behaviors. According to the Society of Psychological Hypnosis (Division 30), hypnosis involves learning how to use your mind and thoughts in order to manage emotional distress, unpleasant physical symptoms, and certain habits or behaviors. Hypnosis has been found to be generally more effective than non-pharmacological interventions, such as physical therapy and pain education. There is growing evidence to suggest that hypnosis has greater influence on the effects rather than the sensation of pain. Findings from systematic reviews suggest that hypnosis may potentially provide symptom relief and improved overall gastrointestinal functioning for patients with IBS, but no effect on secondary outcomes including pain. Hypnosis may be able to reduce stress, relieve anxiety, improve sleep, improve mood, and reduce the need for opioids. Further, hypnosis can enhance the efficacy of other well-established treatments for pain.

• Auto-suggestion – Sometimes people are trained in self-hypnosis, or auto-suggestion, in which they learn to guide themselves through a hypnotic procedure. The suggestive interpretation is provided in soothing, repetitive, fixed phrases that are pronounced for extended periods of time (e.g., 10 to 20 minutes) by the patient. The suggestions refer mostly to the beneficial outcomes rather than to the means in which these outcomes can supposedly be attained. Past research has shown that hypnosis interventions that included an auto-suggestion component evidenced significantly greater weight loss.

• Relaxation – There are several other types of relaxation techniques, including diaphragmatic breathing, progressive muscle relaxation (PMR), and autogenic training. Diaphragmatic breathing is the act of breathing deep into the lungs by flexing the diaphragm rather than breathing shallowly by flexing the rib cage. PMR entails a physical component, which involves the tensing and relaxing of different muscle groups of the body, and a mental component, which focuses on the difference between the feelings of tension and relaxation. Autogenic training involves a daily practice of 15-minute sessions in which the patient is encouraged to repeat a set of visualizations to induce muscle relaxation. The most recent research review indicates there is some evidence that relaxation can reduce pain outcomes in both acute and chronic pain; however, there is evidence that these improvements are not maintained over time.

• Biofeedback – The term “biofeedback” alludes to the function of this modality; “bio” means body and “feedback” is having information fed back to the patient. Biofeedback is the use of instrumentation to mirror psychophysiological processes of which an individual is not normally aware and which may be brought under voluntary control. There are several types of instruments that are typically used in biofeedback training, including the thermistor (temperature), photoplethysmography (heart rate variability), pnuemograph (respiration), electrodermograph (sweat gland activity), electromyograph (muscle tension), and the electroencephalograph (electrical activity in the brain). Biofeedback instruments do not change or influence bodily processes; they merely monitor or measure bodily functions. The implementation of mental exercises is the key and can range from listening to pre-recorded audio -> mindfulness -> relaxation techniques -> self-hypnosis practice. There is strong evidence that biofeedback is effective for reducing the frequency, duration, and intensity of headaches. Biofeedback has also been found to have a potential benefit for pain when using the electromyograph among patients with fibromyalgia.

• Distraction/displacement of attention – The process of diverting the attention of an individual or group from a desired area of focus and thereby blocking or diminishing the reception of undesired information, in this case being the pain signals. Distraction requires the mental capacity to concentrate and the physical ability and energy to engage in distracting activities. There are several examples of activities used for distraction, including humor, crafts, tapping, gaming, reading, writing, and drawing. The distraction is more successful if the patient chooses something they are interested in and must stimulate the major senses in order to be engaging. Keep in mind that the awareness of the pain may return once the distraction ends. Therefore, the patient may want the potential to increase the distraction stimulus when their pain increases. There has been little examination of the use of distraction in chronic pain, but some ancillary evidence suggests that it should be used with caution. More recent studies have shown that virtual reality distraction was shown to be effective for reducing pain when fully immersing the individual in a virtual environment.

• Music therapy – Primarily helps patients improve their health by using music experiences such as free improvisation and singing. Research suggests that drumming serves as a distraction from pain and promotes the production of endorphins and endogenous opiates. Past studies also suggest that active singing may have some benefits in terms of active coping, but further research is required to fully explore such effects. Past research has also shown that music can increase the effectiveness of medical therapies and can be used as an adjuvant with other pain-management programs. Music therapy is often used in some medical hospitals and cancer centers.

• Meditation – A devotional exercise of, or leading to, observation. Meditation is an umbrella term that encompasses the practice of reaching ultimate consciousness and concentration to acknowledge the mind and regulate the individual’s attention. Meditation involves several techniques, including compassion, love, patience, tantra, sexuality, silence, breathing, emptiness, mindfulness, and yoga.
  • Mindfulness – A type of meditation commonly used in pain management. Mindfulness is an exercise in just noticing, or awareness; it is not some special mystical state, nor is it a form of relaxation. There are several types of mindfulness-based interventions available, including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. MBCT uses traditional cognitive behavioral therapy methods and adds in mindfulness meditation. Research has shown that practicing short meditation exercises is a great way to break away from pain, and it may also reduce anxiety, depression, and sleep trouble. There is evidence of improved pain associated with mindfulness interventions. One systematic review addressed somatization disorders, including fibromyalgia, which suggests that mindfulness-based therapies may be effective in treating at least some aspects of the disorder.
  • Yoga – An ancient Indian philosophical practice that pairs physical postures with breath awareness and meditation to bring a sense of contentment to the existential human condition. Yoga is thought to work by increasing embodiment through exposure to bodily sensations as practitioners are often reminded to pay attention to their bodies and focus attention on certain body parts. Moreover, yoga practice emphasizes attention to the breath and encourages steady and even inhalations and exhalations, resulting in vagal nerve suppression. A 2012 national U.S. health survey found that over 13% of the U.S. population practiced yoga, and musculoskeletal conditions and stress were the top health reasons cited for starting yoga. Health practitioners, however, should consider the fit of yoga for their patient before prescribing it. Patients who are low on trait mindfulness might first benefit from practices to improve mindfulness. Also, patients whose attitude toward yoga effectiveness is pessimistic would benefit from learning about the effectiveness of yoga. Yoga practice has been found to decrease low back pain, neck pain, knee osteoarthritis pain, migraines, and pain in patients with fibromyalgia. Further, yoga may be more effective than traditional exercise at decreasing physical pain (Cosio & Demyan, 2020a).

Affective Component: Focusing on Effects that Alleviate Pain

Numerous studies have been conducted in the area of pain and emotion, including stress and pain, negative emotional states and pain, emotional regulation processes and pain, the effects of enhancing emotional regulation on pain, and the relation of emotional distress to treatment-seeking in persons having pain. There are treatments focusing on these effects that alleviate pain, but they seem to have limited effect on pain management. The notion that accessing and exploring painful emotions in a therapeutic relationship makes one better is a widely held belief among several schools of psychotherapy. There are several psychological techniques that address the affective component, including:

• Supportive therapy – A practical approach to treatment that aims to help patients cope with their emotional distress and problems of living using techniques, such as comforting, advising, encouraging, reassuring, and listening attentively and sympathetically. Supportive therapy offers an emotional catharsis for the patient. It may also include education about the patient’s illness and directive coping strategies. The therapist appeals to the patient’s conscious mind rather than interpreting their unconscious. The therapist might also serve as a case manager, interceding on a patient’s behalf with various authorities with whom the patient may be contending. In supportive therapy, the therapist serves as a role model of appropriate behavior, including healthy emotional regulation, and consequently conveys implicitly an adaptive ideology about the way that life ought to be led. Supportive therapy is often included as a condition in clinical trials to provide a rigorous comparison group that controls for nonspecific factors in therapy (such as treatment alliance, time, and frequency of visits) and allows researchers to evaluate any unique benefits of other psychotherapies (e.g., cognitive behavioral therapy).

• Humanistic psychotherapy – The inclusion of a humanistic section diverges from Kreitler and Kreitler’s (2007) original psychotherapy classification system for the treatment of pain. For example, in the original taxonomy, existential and gestalt therapies are considered dynamic therapies. In this manuscript, they are organized under a humanistic heading, along with the person-centered approach, due to shared assumptions, including the belief that people tend toward positive growth. Further, these approaches are phenomenological, in that they are interested in the patient’s subjective report of their life experiences. Further, all three approaches emphasize the therapeutic relationship and see nonjudgmental regard as a curative factor. Lastly, the person-of-the-counselor is considered a vital change mechanism. This requires the therapist to use their whole, authentic self to role-model healthy interpersonal relationships with the patient, including healthy boundaries, distress tolerance, and emotional regulation.

• Person-Centered Therapy – This process-oriented, humanistic approach to therapy was developed by psychologist Carl Rogers in the 1940’s. This treatment seeks to facilitate a patient’s self-actualizing tendency, or an inbuilt proclivity toward growth and fulfillment, using communication micro-skills to develop and convey an understanding of the patient without judgment or opinion. The therapist does this via acceptance (unconditional positive regard), therapist congruence (genuineness), and an empathic understanding. Carl Rogers believed that these three core conditions help liberate their patient so they may confidently express their true feelings without fear of judgment. The therapist therefore creates a nonjudgmental environment wherein patients can explore their true selves without the personal input of others. This judgment and directive free space then allows the patient to discover their values independent of others. Recent clinical trials have found that home-based, telephone-delivered supportive care (using person-centered therapy) performed as well as cognitive behavioral treatments for back pain severity and disability.

• Existential Therapy – This therapy is informed by the existential tradition of European philosophers, such as Kierkegaard and Nietzsche, but it was Rollo May, a psychologist, who brought existential therapy into the mainstream in the middle of the 20th century. Existential therapy is a process-oriented approach rooted in the humanistic tradition. It assumes that people are inherently driven to self-actualize. Like other humanistic psychotherapies, this approach is focused on the here-and-now as opposed to past childhood experiences. Existential theory assumes that anxiety is a normal part of the human condition. It aims to help people cope with macro-level existential issues such as finding meaning in life and cultivating courage in the face of death anxiety. The goal of the therapy is to promote responsibility in the patient through awareness of thoughts, feelings, and choices in order to live an aware, authentic life. There is limited research on the effectiveness of existential therapy with non-oncology populations. While existential therapy outcomes have been investigated, these investigations have been predominantly with oncology patients.

• Gestalt Therapy – This therapy was developed by Fritz Perls and his wife, Laura Perls, in the mid-1900s. Like person-centered and existential approaches, gestalt therapy is a humanistic, process-oriented approach. It promotes the relationship between the patient and the therapist as its most vital intervention. The therapist uses their whole, authentic self to help cultivate biopsychosocial awareness in the patient. A distinct component of gestalt therapy, compared to other theories, is a focus on physical body awareness. Gestalt therapists encourage their patients to notice bodily sensations in order to access patterns of feelings, thoughts, and ultimately behaviors. In gestalt therapy, patients are challenged to identify introjections – value systems that come from outside themselves, rather than from their own self-concept. In gestalt therapy, patients gain exposure to authentic interpersonal contact (with the therapist). Because of this, the person-of-the-therapist serves as an important change mechanism. Further, because of the important role of the therapist’s personhood in treatment, gestalt therapists should complete their own gestalt therapy to ensure they are able to effectively role model characteristics of healthy interpersonal interactions. The objective of gestalt therapy is to enable the patient to shed the incongruent values of others while integrating parts of the self that had been cut off. An increase in self-regulation and authenticity are the ultimate desired outcomes of gestalt therapy. More research is needed on the impact of existential and gestalt therapies on well-being and pain experiences in more diverse pain patient populations.

• Emotional Awareness and Expression Therapy (EAET) – This intervention is based on the principle that life stress accompanied by emotional suppression can lead to chronic over-arousal, dysregulate the brain, and trigger or exacerbate pain symptoms related to fibromyalgia. EAET seeks to reduce stress and improve health by helping patients recognize their own stress‐pain links and recognize that the avoidance of emotionally difficult interpersonal experiences is a key stressor. Therefore, this approach teaches patients to identify, experience, and express their emotions related to stressful experiences, and encourages them to engage in emotionally honest and direct interpersonal communication. EAET uses techniques such as writing about stress, role-playing how to handle difficult relationships, recognizing and expressing anger and other feelings, and being more open with others.

• Meaning-based Control of Negative Emotion – Kreitler and Kreitler (1985) proposed that pain control may be a pattern of cognitive-based, meaning assignment tendencies of the patient. They further assert that changes in these tendencies facilitate changes in the experience of suffering from chronic pain which may help to reduce anxiety and increase coping abilities in pain patients. Cognition is the meaning-processing system that identifies, transforms, retrieves, elaborates, stores, and produces meanings. Meaning itself consists of what is often called cognitive contents, or verbal and nonverbal representations that relate to an input, or an external stimulus, situation, signal from the autonomic system, or thought. These inputs are called "referents" when they serve as anchors for meaning assignment. The content items assigned to a particular referent are called "meaning values." Accordingly, a unit of meaning consists of a referent (e.g., "pain") and a meaning value (e.g., "is depressing, difficult, and reminiscent of crises"). The manipulation of meaning consists of changing the strength of the negative meaning values of the referent by assigning specific, well-defined attributes or comparatives, such as “Pain is a normal feature of the human experience,” expressing interpersonally-shared meanings, and emphasizing actions and sensory-qualities of the referent, such as “Pain is an alarm of a threat which interferes with normal life functioning.” Kreitler and Kreitler (1985) have used a structured protocol which is one to two brief sessions to train individuals in adequate cognitive styles to address anxiety and trauma.

• Dynamic psychotherapy – Research studies investigating dynamic approaches have shown that emotional changes often accompany severe and persistent pain. Dynamic psychotherapy is typically used when psychosocial risk factors play a role in pain symptoms and the goals include long-term adaptation to pain and relief of symptoms. There is evidence to suggest that emotional factors, defense mechanisms often measured by the Minnesota Multiphasic Personality Inventory (MMPI-2), and personality traits can modulate the subjective experience of pain. Dynamic psychotherapy aims to enable insight into the unconscious processes (one’s motivations, conflict resolutions, overcoming trauma, and catharsis) as liberation from emotional suffering impacts pain and its psychological components. Dynamic psychotherapy serves as an umbrella concept for psychotherapeutic treatments that operate on an interpretive/expressive-supportive continuum, which includes psychoanalysis, Adlerian, and more contemporary psychoanalytic approaches such as interpersonal psychotherapy. Overall, past research has shown that short-term dynamic psychotherapy is indicated for patients with psychiatric comorbidity and those with somatoform pain disorder. A systematic review of the literature has shown a range of studies which have investigated the use of short-term dynamic psychotherapy for the treatment of somatic conditions, including idiopathic, chronic pain conditions, severely physically ill with mostly chronic pain, chronic headaches, rheumatoid arthritis, chronic back pain, and pelvic pain or urethral syndrome. In addition, there are some randomized controlled trials that have reported dynamic psychotherapy outperforming mindfulness-based stress reduction and cognitive behavioral therapy on measures of chronic pain.

• Psychoanalysis – Rooted in the theory of evolution, this therapeutic approach was established in the early 1890s by Sigmund Freud. Psychoanalytic approaches emphasize early childhood experiences and caregiver relationships. Its therapeutic techniques aim to explore the unconscious mind and bring repressed fears and conflicts from infancy and childhood into the conscious mind. It does this using intervention techniques, such as dream interpretation and free association, from which Freud believed subconscious thoughts would be revealed. Traditional psychoanalysis is a lengthy process which involves many sessions with a psychoanalyst. It is an example of global therapy which aims to help the patient bring about a major change in their whole perspective on life rather than symptom reduction. Present day attachment theory, with its focus on early life experiences with a caregiver, evolved from psychoanalytic theory.
• Adlerian therapy – Alfred Adler, a contemporary of Freud, developed this therapeutic approach during the early 20th century. Similar to Freud, Adler was interested in the impact of early childhood experiences. Different from Freud, who emphasized sex and aggression instincts, Adler emphasized the importance of social interest and belonging. As a result, Adlerian therapists explore factors such as sibling birth order, lifestyle, and parenting. Adler assumed that children experienced inherent feelings of inferiority and that a crucial developmental goal was to transform feelings of inferiority into social interests aimed at helping the greater good. Adlerian therapists assist patients in uncovering their private logic, including distorted thinking, and style of life in order to help them develop insights, skills, and behaviors. The objective is to identify and reframe basic mistakes and private logic across four phases of treatment: engagement, assessment, insight, and reorientation. While Adlerian therapy has been supported by some research, more testing will likely provide more extensive evidence backing the benefits of the approach.
• Interpersonal psychotherapy – This therapy differs from other traditional psychoanalytic approaches in that it examines current rather than past relationships and recognizes internal conflicts without focusing on them. The main goal of interpersonal psychotherapy is to improve the quality of a patient’s interpersonal relationships and social functioning to help reduce their distress. The therapy provides strategies to resolve problems within four key areas, including interpersonal deficits, unresolved grief, difficult life transitions, and interpersonal disputes. There has also been some preliminary evidence to support the use of interpersonal psychotherapy as a treatment for patients with chronic pain and depression.

• Creative arts therapy – Includes dance or movement-based expression, story and poetry writing, acting, and visual arts in the therapeutic process. While the art-making process has been found to be therapeutic as a stand-alone treatment, it is more often used as a complementary alternative intervention under one of the aforementioned therapies. The purpose of art therapy is essentially one of healing. More studies are needed to better understand the effectiveness of creative art therapy in chronic pain patients.

• Visual arts therapy – Any type of two- or three-dimensional visual art project is conceptualized and executed as a means to express oneself and gain insights into thoughts, feelings, and behaviors. Visual arts projects might include painting, drawing, photography, sculpting, and/or digital art. There are three ways in which art therapy can be facilitated, including studio-based art therapy, group art therapy, and individual art therapy. However, creative arts therapists make these mediums accessible for all types of patients. There are various reasons for the integration of these forms of therapy in complementary, supportive pain management programs, including their stimulation of a positive emotional experience. One rigorous study examined the meaning of chronic pain using visual art interventions and found that patients reported greater introspection and, as a result, a greater understanding of their patterns of thoughts, feelings, and behaviors.

• Psychodrama – This was originally developed by Jacob L. Moreno, and includes elements of theater. It is a type of group psychotherapy where dramatic expression, theatric plays, or body movement are applied to reenact real-life, past situations (or inner mental processes), acting them out in present time. Participants then have the opportunity to evaluate their behavior, reflect on how the past incident played out in the present, and more deeply understand particular situations in their lives. Psychodrama aims to improve patient’s relationships with others and, reciprocally, their self-confidence. There is evidence to support the effectiveness of psychodrama on the expression of suppressed feelings in a sample of cancer patients.

• Play Therapy – A supportive, process-based psychotherapeutic approach used primarily with children 3-12 years of age. This type of therapy is used to help patients explore their lives and freely express repressed thoughts and emotions through play. The goal is to help children learn to express themselves in healthier ways, become more self-compassionate and empathic, and discover new and more positive ways to solve problems. Play therapy has been shown to help buffer pain experiences in pediatric cancer patients (Cosio & Demyan, 2020b).

Cognitive Component: Making Changes in Patient Attitudes Toward Pain

Cognitive treatments aim to improve pain control by facilitating a change in patients’ attitudes toward their pain. The underlying assumption is that cognitions, or thoughts, and beliefs impact the experience of pain. There are several psychological techniques informed by the role of the cognitive component of pain. According to the original classification, they include psychoeducation, cognitive attitude-based therapy (CABT), cognitive coping therapy, and cognitive therapy (CT). The current review expands this category to include psychotherapy approaches that integrate cognitive therapy and behaviorism, including cognitive behavioral therapy (CBT), rational emotive behavioral therapy (REBT), and cognitive processing therapy (CPT). This review also includes cognitive behavioral approaches that integrate mindfulness, such as acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), and mindfulness-based cognitive therapy (MBCT). The expansion of cognitive-informed approaches into pain management helps to evolve, and therefore improve upon, traditional cognitive approaches. It also expands the therapeutic tool belt for health providers working with pain patients. The following is a review of each type of psychotherapy approach for pain, along with a broad overview of their effectiveness for treating pain-related distress.

Psychoeducation

Didactic Information-based Techniques. Past research has recognized the difference between didactic information, or health education, and psychoeducation, and identified the need for separate patient education programming to complement existing chronic pain interventions. Coping is a state of being tolerant, minimizing, accepting, or ignoring things that cannot be controlled, and are skills acquired from psychoeducation through a cognitive route. Learning requires thinking, and learning has the potential to change thinking and behavior. Conversely, self-management is the activity people undertake to create order, discipline, and control in their lives, and are skills typically learned from the didactic information-based technique, or a health education program. Health education programming based on the biopsychosocial approach to pain management emphasizes the patient’s responsibility for self-management, and outcomes are improved when programs include pain education, wellness principles, and sound interventions.

Pain Education Programs. Some hospital systems may offer formal pain health education programs. For example, the Pain Education School program was developed at a Midwestern VA Medical Center in 2009 to address the biopsychosocial health education needs of Veterans who suffer from chronic, noncancer pain. The goals of the program are to share basic principles of pain relief and prevention, provide education about pharmacologic interventions, and introduce services offering nonpharmacological interventions for relief of chronic or persistent, noncancer pain. Such an education-focused, professionally driven program assumes that if individuals are provided with adequate education, they will self-manage illness. Pain education programs have been shown to decrease pain intensity, improve pain knowledge, and change beliefs about pain. While research demonstrates that they make minimal changes in subjective pain experiences, pain education programs have been shown to create positive changes on depression measures.

Therapeutic Neuroscience. Pain is complex and new paradigms of pain (i.e., neuromatrix, nerve sensitivity, endocrine, and immune responses to pain, and neuroplasticity) have introduced the use of nonpharmacological options in the treatment of pain. However, patients continue to be focused on how pain works, and their interest appears to have a purpose. Growing evidence supports that teaching patients more about the neurophysiology and biology of pain allows for decreased pain, psychometric measurements, increased movement/function, and compliance with therapy. Therapeutic neuroscience education is predominately oriented in physical therapy, but the programming is complimented by psychological concepts. It aims to reduce threat perception through education in order to shift patients away from disuse and disability. Therapeutic neuroscience education programs have been shown to decrease pain, improve pain beliefs, and improve cognitions, pain thresholds, and movement performance.

Cognitive Attitude-Based Therapy (CABT). Pain management may be attained by shifting patient’s attitudes concerning the etiology of pain, diagnostic expectations, treatment expectations, and outcome goals. The underlying change mechanism of CABT asserts that enhancing positive attitudes or weakening dysfunctional beliefs can promote pain management. There are different inventories used to measure pain attitudes and beliefs, including the Pain Beliefs Questionnaire, the Survey of Pain Attitudes, Pain Information and Beliefs Questionnaire, and the Pain Beliefs and Perception Inventory. Providers can change attitudes about pain through group discussions, supplemental support materials, and explanatory models.

Cognitive Coping Therapy

Patients’ beliefs about their pain has been shown to be a good predictor of long-term rehabilitation. Pain management can be accomplished by promoting patient acquisition of adequate cognitive skills (e.g., active problem solving, using coping self-statements, and humor) and forfeiture of inadequate cognitive skills (e.g., catastrophizing and overgeneralization). Providers can accomplish these tasks by providing information, discussion, modeling, reinforcement, rehearsal, generalization to everyday life, and support for maintenance. Oftentimes, these cognitive coping strategies are implemented in CT and CBT.

Cognitive Therapy (CT). Aaron Beck developed CT, which focuses on the impact of the negative cognitive triad: negative thoughts about the self, the future, and the world at large. He asserted that the link between thoughts and emotions was causal. CT aims to help patients identify maladaptive patterns in thinking, including defining and labeling the patterns. The goal is to help patients discover their underlying core beliefs and schemas, which are thought to fuel depressive and anxious symptoms. According to Beck, schemas can be reduced to deep, underlying worries about being unlovable or helpless. CT aims to improve awareness of thought patterns, with the ultimate goal of transforming negative thought patterns into more accurate, adaptive thinking that will improve the quality of life of the patient and likely result in adaptive behavior change.

Second Wave of Psychotherapy

Traditionally, the theory of behaviorism defined behavior as that which can be seen and measured. Over time, the definition of what constitutes a behavior (or not) expanded to include cognition, or thinking, as a behavior, subject to the same tenets of behaviorism’s learning theory. The inclusion of cognition as a behavior under the theory of behaviorism marks the second wave of behaviorism. Thus, cognitive theories can be used on their own as a stand-alone approach, separate from behaviorism, or used in conjunction with behaviorism, as indicated by the second wave of psychotherapy. Research on cognitive approaches demonstrate an increase in reported self-efficacy and a decrease in pain catastrophizing in samples of chronic pain patients.

Cognitive Behavioral Therapy (CBT). CBT is a structured, time-limited, present-focused approach to psychotherapy that helps patients engage in an active coping process aimed at changing maladaptive thoughts and behaviors that can serve to maintain and exacerbate the experience of chronic pain. CBT protocols introduce cognitive concepts, such as automatic thinking and cognitive restructuring. Cognitive distortions, unconscious operations of the mind, are categories of automatic thinking. Negative cognitive distortions fall into four broad categories, including overgeneralization, mental filters, jumping to conclusions, and emotional reasoning. Cognitive restructuring is a useful tool for understanding and turning around negative thinking. Cognitive restructuring requires an observation of distorted thought patterns, challenging distorted thought, and re-scripting the distorted thinking that lies behind them. In engaging in this active process, the patient learns to approach situations in a positive frame of mind. CBT for pain is grounded in the notion that pain is a complex experience, influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior. CBT for pain has three components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills. The goals of CBT are to reduce the impact pain has on the patient’s daily life; to teach skills for coping better with pain; to improve physical and emotional functioning; and to reduce pain intensity and consequently the reliance on pain medication. Past research has shown CBT to be highly efficacious in the treatment of fibromyalgia, headaches, low back pain, osteoarthritic knee pain, and rheumatoid arthritis.

Rational Emotive Behavioral Therapy (REBT). Bridging the gap between CT and behavioral therapy is a type of CBT called REBT, developed by Albert Ellis. REBT has been used to treat rage, anxiety, frustrations, social phobia, shyness, and sexual dysfunctions. REBT brings awareness to automatic thought patterns in order to achieve a more desired, adaptive emotional outcome. REBT is based on the notion that people are capable of rational and irrational thought, and it is the capacity for irrational thought which causes distress. For example, an irrational thought may be, “if I experience any pain, it is terrible and I am unable to live a happy, fulfilling life.” REBT aims to modify irrational thoughts and uses the A-B-C model as its predominate assessment and intervention tool. The A-B-C model purports that interpretations of the environment (or activating event–A) affects cognitions (or the beliefs about the event–B), which in turn drives our emotions and bodily sensations (or consequences–C).

Cognitive Processing Therapy (CPT). CPT is a time-limited, cognitive-based treatment approach developed to treat trauma symptoms. When an individual suffers from trauma, they may find themselves thinking very differently about themselves and their environment, particularly in terms of safety, trust, control, esteem, and intimacy. These thoughts can lead to negative emotions, such as fear, anxiety, guilt, and anger, and can halt recovery. CPT focuses on teaching a set of skills that will challenge these negative thoughts and gain control over the impact the thoughts have on the patient’s life. Many chronic pain patients also have a history of trauma. For patients who suffer from both trauma and chronic pain, pain sensations can trigger trauma symptoms and vice-versa. Treatment for trauma symptoms has been found to reduce pain and can help the patient better manage their pain levels and symptom flare-ups. Patients appear to benefit from receiving an integrated treatment with components of CPT and CBT for pain and trauma symptoms.

Integration of the Third Wave

CBT has historically enjoyed the spotlight in the psychotherapeutic treatment of pain. More recently it has been used as a foundation to inform new approaches. Instead of aiming to modify maladaptive thought patterns, newer cognitive-informed approaches aim to increase awareness of thought patterns without judgment or attachment to them using mindful awareness. Mindful awareness results in an unlinking of thought and emotion, which results in thoughts being present without an automatic emotional reaction. Approaches that stress acceptance of cognitive behaviors with curiosity rather than judgment are referenced as the third wave of behaviorism. Third-wave approaches have been investigated for their impact on chronic pain patients. They include acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), and mindfulness-based cognitive therapy (MBCT).

Acceptance and Commitment Therapy (ACT). ACT is a form of clinical behavior analysis that uses acceptance and mindfulness strategies mixed with commitment and behavior-change strategies. The primary goal of ACT is to increase psychological flexibility. ACT is informed by functional conceptualism and relational frame theory. Relational frame theory asserts that learning is contextualized, relational, and bidirectional. ACT is highly experiential and its efficacy has been found to vary as a function of patient commitment and participation in treatment. The experiential elements of ACT challenge patients to learn and practice new and more flexible ways of responding to pain. The goal of ACT is to shift patients’ primary focus from reducing or eliminating pain to a focus on fully engaging in life, while accompanied by the pain. ACT applies six core treatment processes (willingness to accept, contact with the present moment, observing the self, cognitive diffusion, values, and committed action) through different experiential exercises to create psychological flexibility. ACT’s underlying theoretical influences include Skinner’s Theory of Radical Behaviorism, which focuses on the reciprocal nature of behavior and the environment. Past research has shown that ACT for chronic pain interventions decrease pain intensity, functional disability, psychological distress, and have shown improvements in pain interference among individuals with chronic pain.

Dialectical Behavior Therapy (DBT). Informed by attachment theory, DBT was developed by Marsha Linehan in the late 1980s. It was developed to treat those who met criteria for borderline personality disorder, specifically suicidal thoughts, intentions, and gestures, which are symptoms that often accompany these patients. DBT is structured to help clients develop insight and skills to manage their thoughts, emotions, and behaviors. Four modules make up DBT, including mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. The mindfulness module aims to cultivate a nonjudgmental awareness of both internal and external stimuli and seeks to replace judgment with curiosity. Once a foundation of mindfulness has been developed, a focus on skill acquisition begins across the remaining three modules, which is needed for the development of healthy interpersonal relationships. While DBT offers a theoretically feasible effective psychotherapeutic approach for pain management, there is very little research on the effectiveness of DBT with chronic pain patients. One study showed improvements in pain intensity, catastrophizing, fear, depression, sleep, and acceptance of pain as a result of DBT. While DBT shows promise, more research is needed on the effectiveness of DBT on chronic pain patients, specifically those who report high interpersonal distress and less treatment gains with traditional CBT.

Mindfulness-Based Cognitive Therapy (MBCT). The development of MBCT was informed from both CBT approaches and mindfulness approaches, specifically mindfulness-based stress reduction (MBSR) developed by Kabat-Zinn specifically to treat treatment resistant chronic pain. MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. Like MBSR, MBCT is a manualized treatment, but was intended to be used to treat depression and found to be effective with pain management. It aims to increase bodily awareness and acceptance of sensory experiences. MBCT performs similarly to psychoeducation for pain interference, acceptance, and catastrophizing. MBCT performed better than treatment-as-usual in patients’ ability to self-regulate and tolerate uncomfortable bodily sensations. MBCT may also be effective for individuals with severe headache and for persons who accept their pain (Cosio & Demyan, 2020c).

Behavioral Component: Using Learning Processes

Rooted in learning theory, behavioral treatments for chronic pain predominately focus on addressing the anxiety and hypervigilance for signals of possible pain coupled with heightened fear of possible consequences. The goal of treatment across behavioral approaches is to increase daily lifestyle functioning as opposed to decreasing nociception. However, behavioral approaches appear to work best with patients who understand this concept and therefore accept their pain condition. For example, Kreitler and Niv (2007) found that wishing that chronic pain would disappear served as a maladaptive coping strategy and treatment barrier. The original Kreitler and Kreitler (2007) classification offered three examples of behavioral therapies for the treatment of chronic pain and pain behaviors, including behavioral therapy (BT), operant behavioral therapy (OBT), and environmental therapy (ET). The following review expands the behavioral component to include functional analytic programs (FAP), solution-focused brief therapy (SFBT), and reality therapy (RT), and offers a broad overview of each type of therapy and their effectiveness for treating pain-related distress.

Models of Behaviorism: Learning Theory

Overall, behavioral therapies are informed by three theories of learning: classical, operant, and social learning. Classical conditioning is a type of learning by association, where learning takes place due to the pairing of a neutral stimulus with an unconditioned stimulus. After enough pairing, the neutral stimulus becomes a conditioned stimulus. The important characteristic of classical conditioning is that the neutral stimulus be presented before the unconditioned stimulus. An unconditioned stimulus is akin to a biological, instinctual response – it is innate, known but not learned. For example, the startle response (to a loud noise) is an unlearned response shared by all humans. With consistent pairing, an organism learns to associate the precursor with the loud sound. Eventually, with enough pairings, there is a learned fear response to the precursor of the loud noise.

Whereas in classical conditioning the neutral stimulus is presented before the unconditioned stimulus, in operant conditioning the consequences which occur after the behavior result in learning. The tenets of operant conditioning offer guidance on the impact of caregiver behavior on patients’ pain behaviors. Pain behaviors are overt or subtle behaviors that serve to reinforce pain identity and inhibit treatment outcomes. Initially considered adaptive for acute pain, pain behaviors become maladaptive over time in that they have been found to exacerbate chronicity and decrease functioning and quality of life. Finally, Bandura (1977) demonstrated the importance of observational learning in his social learning theory. His classic Bobo doll study showed that individuals learn to link behaviors and consequences through witnessing the consequences of others’ behavior. These observed consequences therefore inform future behaviors for the observer. For example, a classic study found that preoperative patients who shared a hospital room with a postoperative patient, therefore witnessing their recovery, were less anxious prior to surgery and had a shorter hospital stay compared to their preoperative counterparts in a private room, or those who shared a room with another preoperative patient. Because of the focus on observable behavior, behavioral treatments often target pain behaviors, such as facial grimacing, limping, and vocalizations such as moaning.

Behavioral Therapy. In behavioral therapy (BT), pain control is attained by reinforcing adaptive behavioral strategies (e.g., active problem-solving, exercising, return to work, engaging in social activities) and avoiding non-adaptive behavioral strategies (e.g., excessive use of drugs, overcautious movements, gradual complaining). The primary goal of BT is to enhance adequate coping by using traditional behavioral techniques such as writing in a diary, setting specific goals, reinforcement (rewards and punishments), rehearsal, and generalization of coping strategies. Oftentimes, behavioral coping strategies have been integrated into other cognitive therapies, such as cognitive behavioral therapy and dialectical behavior therapy, which were reviewed in a previous section on the cognitive components of pain. BT is often practiced in group format. There is limited literature regarding the optimal dose of behavioral interventions for pain, however brief treatments have garnered empirical support. Behavioral therapy has been found be effective for chronic pain across studies. There is reportedly little to no difference between cognitive, combined (e.g., cognitive behavioral), or operant behavioral therapy for pain relief.

Operant Behavioral Therapy. Operant behavioral therapy (OBT) programs were originally applied to the treatment of pain by Fordyce in the 1970s, and moved beyond the closed disease model aiming instead to alter environmental contingencies to reinforce adaptive behavior. In OBT, patients gain awareness of maladaptive pain behaviors (e.g., medication misuse and excessive use of doctor visits) and learn to differentiate them from healthy coping. They learn to recognize the maintaining factors of pain behavior related to others and personal maladaptive cognitions (e.g., catastrophizing). Physical exercise is an essential part of OBT for training of motor perception, increasing personal physical activities and reducing avoidance behavior, intake of medication, and excessive solicitous caregiver behavior. Partner behavior has been found to serve as an important environmental contingency impacting pain behavior. Specifically, solicitous partner behaviors have been found to be proceeded by maladaptive, nonverbal pain behavior regardless of age, gender, and pain intensity level. As a result, OBT programs work closely with partners/important others in the patient’s life and aim to understand and adaptively alter solicitous and negative partner response behavior. The more partners reinforce adaptive behaviors, the less pain behavior is displayed. The goal of OBT is to reduce patient pain behaviors and ultimately increase their quality of life. In a meta-analysis, researchers found moderate qualitative evidence for operant therapy to be more effective than the waiting list control. Further, OBT has been found to be more effective than cognitive behavioral therapy (CBT) at reducing pain behaviors and physical impairment. The same study showed OBT and CBT performed similarly at reducing pain intensity at follow-up compared to an attention placebo condition.

Environmental Therapy. Environmental therapy (ET) is based on conditioning. In ET, pain control is achieved through changes in the patient’s environment. Removal from the environment may be actual physical removal to another geographic location, such as a clinic, recovery house, or other setting. Removal can also take the form of changing stimuli or objects in the regular environment, such as furniture (chair, bed, sofa), color of walls, and other objects with which the patient has a lot of contact. Looser definitions of the term environment may include changes to wardrobe and a person’s aesthetics, such as hairdos. Environment alterations may include changes in lighting or sounds, but may even be virtual. However, exposure to nature appears to be the most widely investigated environmental therapy for the treatment of pain. These investigations include in vivo or in vitro exposure to natural landscapes. Investigations into the impact of nature versus urban environments showed that exposure to a nature environment positively impacted both physical and psychological health in samples of chronic pain patients. Moreover, a recent review of 64 studies that investigated the impact of the Japanese practice of forest bathing on health indices found improvements in heart rate variability, blood pressure, inflammation, and endocrine functioning as a result of exposure to nature or nature scenes. They also concluded that the same effects can be achieved by watching videos or viewing pictures of nature scenes, making this approach far more accessible for those who are unable to travel to a different environment because of physical or geographic limitations. Moreover, virtual reality (VR) of scenic imagery has been found to reduce pain intensity, pain unpleasantness, and pain rumination. VR has been found to be more effective than two-dimensional video for the treatment of pain and pain behaviors.

Functional Analytic Programs. Functional analytic programs (FAP) were developed by Kohlenberg and Tsai (1991) as an effort to understand how radical behavioral aspects of the therapeutic alliance promoted change. FAP is a present focused, process approach which requires healthcare providers to have awareness of how their own reactions may have a reinforcing effect on their patients’ maladaptive pain behaviors. Healthcare providers are encouraged to communicate the patterns they notice within the interpersonal interactions they have with their patients in order to increase the patient’s awareness of these patterns. Despite limited research, one study investigated FAP group therapy for patients with chronic pain. Results indicated that FAP appears to be a promising approach for treatment-resistant chronic pain patients.

Solution Focused Brief Therapy. Solution focused brief therapy (SFBT) is a strength-based, time-limited, future-focused therapy developed by Shazer and Berg (1997) out of a desire to understand what therapists and patients do together that produce meaningful change. SFBT assumes that people are fully capable of change, and that the solution is not necessarily related to the problem. With SFBT, healthcare providers assess and treat patients using techniques such as the “miracle question” to understand the patient’s vision of their goals for treatment. The miracle question asks the patient the following question: “What if a miracle happened in the middle of the night and the problems that brought you to treatment magically disappeared? But, because you were sleeping, you do not know that the miracle occurred. What will be different in your day to show you that the miracle happened? What will be the first thing you notice?” The patient then walks the healthcare provider through their day, identifying differences that would indicate improvement from the perspective of the patient.

An eight-week SFBT intervention has been shown to be effective at decreasing pain interference at follow-up. The same study showed a significant increase in both self-efficacy and well-being at follow-up. Another study qualitatively investigated impact on the SFBT group and identified five themes from participants’ responses to the program, including appreciation for the opportunity to share their expertise, comradery of the group, empowerment to push themselves to achieve tasks of daily living, and concern about maintaining their gains post-group. While the research has demonstrated support for SFBT for the treatment of chronic pain, more research is needed on the impact of SFBT on pain behaviors. Specifically, most investigations into the impact of SFBT for chronic pain has used a group format. To better understand the underlying mechanisms of SFBT, it would be important to investigate the outcome variability accounted for by individual SFBT therapy versus an SFBT group format.

Reality Therapy. Reality therapy (RT) is a present-focused, psychotherapeutic approach that emphasizes responsibility and choice in order to facilitate behavior change. This approach to therapy was developed at the Veterans Administration hospital in Los Angeles in the early 1960s by William Glasser. Guided by control theory, RT rejects the medical model and maintains that suffering is the result of an unmet need in one or more of five domains: love and belonging, power, fun, survival, and/or freedom. RT therefore aims to first increase the patient’s awareness of their five domains, and second, helps them to make appropriate approximations toward change that align with their authentic needs across domains assessed to have deficits. While RT emphasizes responsibility, it also prioritizes the provider-patient relationship. Nonjudgmental active listening and positive affirmations are important factors in helping patients gain awareness and make authentic, adaptive life changes. Research on the use of RT with patients with specifically chronic pain has been generally scant in the existing literature. However, investigations of the impact of RT for individuals with developmental disabilities show promise (Cosio & Demyan, 2020d).

Pain Interventions in Different Settings

How to Utilize Acceptance and Commitment Therapy for Pain in Primary Care

More than one third of people with chronic pain have been found to drop out of treatment. Patients often report discontinuing treatment due to adverse experiences, such as medication side effects. However, untreated chronic pain often leads to increased disability and lower quality of life. Efforts have been made to address barriers to chronic pain treatment through enhancements in interventions and delivery models.

Self-management approaches have been identified as a gold standard for chronic pain treatment. Traditional acceptance and commitment therapy (ACT) has been found to be effective at increasing self-management. However, time, transportation, and even the COVID-19 pandemic serve as barriers to accessing and continuing treatment regimens. Fortunately, ACT has been developed and tailored for remote delivery via telemedicine. Here, we review the effectiveness of virtual ACT for chronic pain and provide tips for how to enhance the conduct of the intervention.

Benefits and Risks of Using Telehealth in Chronic Pain Management. Online treatment delivery has specifically been lauded for its ability to address several barriers to care. Telemedicine has the benefit of no transportation and travel-time issues, and improved treatment access for rural patients. Additional benefits reported include the flexibility that comes with telehealth delivery, resulting in patient empowerment through participation and a reduction in burdened health provider workloads. Telehealth is, however, not considered appropriate for new patients who require a physical exam, those with new and changing symptoms, diagnostically challenging and medically complex patients, and for patients put at high-risk for medication misuse or abuse. Other reported limitations of telehealth include challenges when developing a relationship between the provider and patient, unrelatable intervention content, issues around technology literacy, problems with up-to-date technology devices, and unstable internet access. Further, there may be privacy issues when discussing sensitive information where others might be present, as well as possible distractions in the home environment.

Virtual ACT for Chronic Pain. ACT is a mindfulness-based, behavioral, psychological treatment that has been found to be effective in the treatment of chronic pain, specifically pain acceptance. There are numerous protocols available in the literature about how to conduct ACT interventions in-person for patients with chronic pain. One of the first protocols released to the public was a four-session intervention, which combined individual and group treatments and established the feasibility of utilizing ACT to treat chronic pain. Soon thereafter, an eight-session ACT intervention was presented, but was found to have a similar coverage of topics (e.g., activity-pacing, goal-setting, and homework) typical of a traditional, cognitive behavioral therapy protocol. At that time, a self-help book was released, which provided more details, but served better as an introduction to ACT therapy rather than as a protocol. A previous section discussed the use of ACT in primary care. Future ACT protocols were generated by incorporating, organizing, and expanding upon the aforementioned works to develop ACT-consistent group protocols to meet the needs of the chronic-pain population. In fact, the content of one of the 10-session ACT group interventions is described along with some examples of its application in the literature.

Research Findings on Telehealth-ACT. Telehealth-ACT and traditional, in-person ACT interventions have been compared for effectiveness. Outcomes from studies comparing these two types of interventions indicate no differences between their effectiveness. Participants in guided interventions have been found to complete more treatment modules compared to those in unguided treatments. Several telehealth-ACT interventions have been developed and investigated for the treatment of chronic pain, including ACTsmart, pain tracker self-manager (PTSM), and iACT.

• ACTsmart is a telehealth treatment delivered to the patient’s smartphone through micro-learning modules. It has been found to have a 90% treatment retention rate with participants completing 84% of the content. In the same study, patients sent, on average, approximately six chat messages to their therapist over the course of treatment, and providers spent approximately 15 minutes a week on each patient.

• Pain tracker self-manager (PTSM) is another telehealth-ACT treatment. In a pilot study, PTSM has been found to positively impact self-efficacy, activity engagement, pain intensity, and interference.

• iACT is a telehealth-ACT intervention that uses microlearning and focuses on treating pain interference. It includes seven themed chapters with audio and video files in each, two telephone contacts, and weekly online contact with a provider. Treatment demonstrated improvement in pain acceptance, and all participants reported positive behavior change with gains maintained at 12-month follow-up.

Enhancing ACT Telehealth Interventions for Pain. The recent pandemic provided a need for psychotherapists to adapt traditional in-person ACT interventions to telehealth delivery. To ensure that the intervention is engaging, it is helpful to provide visual and tactile learning opportunities. This can be accomplished by mailing a participant a hard copy of a booklet, and/or using the share screen option on video conferencing platforms to share additional information about the ACT theoretical framework. Moreover, through the use of metaphors, videos, and at-home exercises, providers can provide a highly experiential treatment through telephone, videoconferencing, and internet platforms. An important initial task of treatment is to develop a trusting relationship and to orient the patient to the theoretical framework of the ACT intervention, which focuses on perspective change, pain acceptance, and learning to observe thoughts so as to uncouple thoughts and feelings/behaviors. One way to do this is by having the person with chronic pain watch a video titled, “Small Pleasures/ Mikpec Xapec (2008),” which can be found on YouTube. The video tells the story of Eftichis, a boy who many years ago had an experience that made him see life from a different perspective. Additional ACT metaphors that are helpful to use during the initial phase of treatment include the “Two Mountains Metaphor,” which explains how the provider is not guiding from the top of the mountain but rather from a mountain across from the participant’s. Further, the “Roller Coaster Metaphor” normalizes the ups and downs of treatment.

Exploring the ACT Principles from Home. The hexagon used to explain the ACT theoretical framework begins at the top with being mindfully present in the moment. Providers can define and explain mindfulness to patients, but it may be helpful to also have the person with chronic pain watch a video titled, “Why Mindfulness is a Superpower: An Animation,” which can be found on YouTube. This may also be paired with a discussion about “experiential avoidance,” which includes the person with chronic pain exploring how they have taken steps to escape pain or numb feelings brought up by their pain in the past. Such a discussion can be augmented with the use of the “Person in the Hole” metaphor. This metaphor highlights the need for the right tools and the right instrument training to get out of a hole. People with chronic pain often compare other people’s external appearance to their internal experience because things seem to be working for them. Control works when manipulating external systems, but can backfire when applied to private experiences. Again, this discussion can be augmented with the use of several additional metaphors. The “Quicksand Trap” metaphor highlights the paradox of how working hard not to sink in the sand actually makes matters worse. It shows how a lot of energy can be spent in self-protection rather than what is valued. Similarly, the “Tug of War with a Monster” metaphor demonstrates that the effort to battle with the “monster” of pain is far more exhausting compared to simply observing it. This metaphor can be demonstrated with an at-home exercise. In this exercise the patient is asked to push a stress ball, which is a stand-in for the monster, against a wall with their hand, and then compare that effort to just watching the ball lay on their lap. Perhaps the most popular metaphor to demonstrate the importance of acceptance and surrender is the “Chinese Finger Trap.” Providers may actually keep some of these bamboo finger traps on hand to demonstrate how the struggle actually tightens the trap around the finger, whereas relaxing loosens the trap so that the fingers can be released. For telehealth delivery, the bamboo finger traps can be mailed to the patient and demonstrated together via a video-conferencing session, or with instructions for a self-paced intervention.

When pivoting to the right of the hexagon, one comes across the valued living and choice principles. These concepts can be explained to the person with chronic pain, but it may be helpful to also have them watch a video, “Values vs. Goals by Dr. Russ Harris,” on YouTube. If you pivot further to the right, the person with chronic pain moves away from a lack of action to setting goals according to values and carrying them out responsibly. The concept of committed action can be discussed, but providers may also want to use the “Pen” at-home exercise. In this exercise the patient is asked to try as hard as they can to pick up a pen. What happens? They either pick up the pen or they don’t. This is compared to their commitment to action, they do it or they don’t – there is no in between.

When pivoting to the left of the hexagon, the person with chronic pain moves away from their avoidance and toward allowing experiences to come and go without struggling with them. Often, providers can explain the “Joe the Bum” metaphor and/or have patients watch the video, “The Unwelcome Party Guest: an Acceptance and Commitment Therapy (ACT) Metaphor,” on YouTube. This video depicts a main character throwing a party where an unwelcome guest arrives and the different outcomes one may face dealing with them. Providers can use the “Garbage Can” at-home exercise to illustrate how additional suffering is added to their pain when they do not learn to accept it. Participants are asked to use a small garbage can, or other object, and hold it away from their body and compare that experience to embracing it close to their body.

Pivoting further to the left in the hexagon, the person with chronic pain moves away from cognitive defusion – seeing thoughts and feelings as fused – toward learning to perceive thoughts, images, emotions, and memories as what they are, not what they appear to be. Providers can explain the concept of cognitive defusion but may also want to use the “Arm Raise” at-home exercise. The person with chronic pain is asked to raise their arm while saying “I can’t lift my arm.” This illustrates the separation of thoughts from the body. Thoughts are just thoughts, physical sensations are just physical sensations, nothing more, nothing less. Essentially, just because you think it, doesn’t make it true. Another at-home exercise asks participants to cover their eyes with their hands and look at what they see, then to move the hands about a foot away from their face and look at what they see, and then again lay their hands on their lap and look at what they see. This illustrates how focusing so closely on pain can distort one’s perceptions. The distance offers a more accurate, clearer perception. Mindfulness encourages cognitive defusion, and it may be helpful to have them follow along by watching a video on YouTube titled “Leaves on a Stream,” which encourages observation of thoughts where the patient experiences themselves not as the thinker, but rather as the curious witness of the thoughts.

The hexagon used to explain the ACT theoretical framework ends at the bottom with self-as-context versus content. When pivoting down, the person with chronic pain moves away from using one perspective to accessing a transcendent sense of self, a continuity of consciousness that is ever changing. This principle is perhaps the most difficult to understand in ACT and is best explained through experiential activities at-home. One activity instructs the patient to put an object in front of them, close their eyes, and then asks them to switch opening one eye then the other, which switches their perspective without changing the object. It may also be helpful to have them watch three different videos on YouTube: “Passengers on a Bus: an Acceptance and Commitment Therapy (ACT) Metaphor,” “Demons on the Boat - an Acceptance and Commitment Therapy (ACT) Metaphor,” and “Struggling with Internal Hijackers?” (Cosio & Demyan, 2021c).

How to Deliver Cognitive Behavioral Therapy for Pain in Primary Care

Cognitive behavioral therapy (CBT) for pain management is based upon the cognitive behavioral perspective of pain. The cognitive behavioral model is grounded in the notion that pain is a complex experience that is influenced by underlying pathophysiology and the patient’s thoughts, feelings, and behaviors. Thus, CBT interventions engage patients in an active coping process aimed at changing maladaptive thoughts and behaviors that serve to maintain and exacerbate the experience of chronic pain. The American Psychological Association recognizes the long-standing effectiveness of CBT for the treatment of chronic, noncancer pain. Traditional CBT has been shown to be highly efficacious particularly in the treatment of fibromyalgia, headaches, low back pain, osteoarthritic knee pain, and rheumatoid arthritis pain among other pain conditions. Specifically, past research has shown that CBT for chronic, noncancer pain decreases pain intensity, increases readiness to adopt a self-management approach, decreases pain severity and interference, decreases functional disability, decreases catastrophizing, decreases levels of distress, and creates changes in coping among patients with chronic pain.

Cognitive behavioral therapy is a structured, time-limited, present-focused approach to psychotherapy. It asserts that distorted thinking has a significant, adverse impact on pain symptoms and pain behaviors, and that there is a reciprocal relationship among thoughts, feelings, and behaviors. CBT aims to help patients first develop awareness of their dysfunctional thinking patterns and maladaptive behaviors. Then, through Socratic questioning and psychoeducation, the patient learns to ask disputing questions in response to dysfunctional, automatic thoughts. Dysfunctional thought patterns are slowly replaced with adaptive, rational thoughts. Rational thoughts in turn result in positive feelings and adaptive behaviors. CBT is traditionally a time-limited intervention comprised of 12 to 16 sessions over three to six months delivered in specialty care settings. For example, CBT for chronic pain has been disseminated nationwide by the VA Office of Mental Health Services and National Pain Management Program Office. Some efforts have been made in the healthcare system to reduce patient mental health stigma, improve patient outcomes and access to behavioral health care, and reduce the systemic burden on specialty mental health services by providing these treatments in primary care. Unfortunately, evidence suggests that CBT for chronic pain is underutilized in health care settings despite its apparent benefits. In response, brief psychosocial approaches targeting pain-related disability are ideally suited to address the concerns outlined in more integrated care settings.

Brief Interventions. Brief interventions are informed by research that has shown that improvement occurs very early in treatment. Practically, brief interventions minimize use of patient and providers’ time and allow for greater accessibility to services. Treatments that require less of a time/length commitment from patients may gain a higher level of engagement and improve retention. Brief interventions demonstrate efficacy compared to lengthier therapies whose effectiveness may be not incremental. Brief interventions have also been shown to bring about clinically significant patient improvement, leading to reduced symptoms, improved functioning, and social integration, in as few as two sessions when delivered in an integrated primary care setting. These changes have been shown to be robust and stable over a two year follow-up period. Furthermore, group-based formats of brief interventions have been found to provide an additional source of support for patients with chronic pain and to significantly reduce wait times for pain management services.

Brief CBT for Chronic Pain (bCBT). It is only in the last decade that abbreviated, modular forms of CBT treatment have been developed and demonstrated for use in primary care settings. The earliest mention is found in a 2009 handbook of cognitive behavioral approaches in primary care, which provides patient encounter guidelines, basic skills for evaluation, and lessons in CBT for primary care physicians. In 2012, Cully and colleagues published a protocol in an article exploring the implementation of brief CBT in a primary care setting for symptoms of depression and anxiety in a sample of medically ill patients with chronic cardiopulmonary disease. In 2019, Beehler and colleagues explored the relative impact of each of six brief CBT for chronic pain (bCBT) treatment modules (30 minutes each) on patient outcomes in primary care to both improve treatment decision-making and inform future research efforts. They found that a composite measure of pain intensity and functional limitations (as measured using the Pain, Enjoyment of Life, and General Activity scale, or PEG) showed statistically significant improvements by the third appointment. Pain-related self-efficacy outcomes also showed a similar pattern of improvements. Furthermore, the research team assessed patients’ perceptions of the acceptability and utility of the bCBT intervention. Patients’ responses suggest the intervention is viable and acceptable in a primary care setting.

More recently, Martinson and colleagues examined the effectiveness of a bCBT group (six sessions, 50 minutes each) for patients in primary care with mixed idiopathic chronic pain conditions. Specifically they investigated the impact of treatment on patients engaged in differing levels of opioid medication use. Results from the study found that there were no significant treatment-related differences between patients taking opioids compared to their counterparts. They also found that participation in the treatment group resulted in statistically significant improvement across several variables, including pain symptoms, physical functioning, sleep problems, pain-related anxiety, pain catastrophizing, and depressed mood. They concluded that a bCBT group can be effective in a real-world setting and aligns with the primary care model.

Delivery of CBT by Frontline Providers. The question still remains whether a certain type of professional degree, level of training, or expertise is required to deliver CBT efficaciously to patients with chronic pain. Studies have investigated the delivery of CBT by non-mental health, licensed professionals, including dental hygienists, nurses, and physical therapists. There is evidence to show that psychologists are more effective than therapists with less training. Nicholas and colleagues (2011) noted that CBT facilitated by interventionalists who were non-psychologists appeared not to be superior to the usual care. This finding could be due to a number of different factors, including lack of knowledge about CBT, reimbursement problems, time constraints, and/or patient reluctance to participate in the intervention. Main and colleagues (2011) also highlighted the momentous practical and philosophical shift required of non-psychologists delivering CBT for the treatment of chronic pain. Both research teams suggest that gaps in treatment outcomes between psychologists and other licensed professionals can be addressed through further training in CBT. For example, a mixed group of treatment providers including nurses and physical therapists trained to deliver CBT to a sample of patients with low back pain produced outcomes demonstrating significant patient gains across disability functioning, pain self-efficacy, physical, and mental health. Further, these gains were maintained at 3, 6, and 12 months.

Group Intervention. Given the research supporting the effectiveness of bCBT group interventions, an experimental intervention was designed and delivered to a sample of patients with chronic pain. The current intervention consisted of four, 90-minute sessions, once a week. The Pain bCBT group intervention was adapted from a manualized “Treatments That Work” protocol. The protocol reviews pain education topics, such as chronic pain syndrome and theories of pain. The protocol introduces cognitive concepts, such as automatic thinking and cognitive restructuring, and behavioral strategies, such as relaxation techniques (diaphragmatic breathing, progressive muscle relaxation, and visual imagery), time-based activity pacing, and pleasant activity scheduling. In addition to these standard topics, additional themes related to anger management and stress management are reviewed because they have been deemed especially important within the Veteran population. Group therapy for chronic pain management has become a common treatment format. Using a group format makes the intervention more time-efficient for providers, provides a mechanism for patients to learn coping skills from others, helps patients realize they are not alone, and helps patients gain valuable social support from others.

Methods and Materials. A sample of 45 Veterans ranging from 18 to 89 years old who suffer from chronic pain were recruited from the pain education program at a Midwestern VA Medical Center for the Pain bCBT Group. Veterans voluntarily participated in the groups and were free to withdraw at any time. As part of the introduction to the Pain bCBT groups, all participants completed quality assurance outcome measures which included pain, enjoyment of life, and general activity (PEG), perceived global distress (PGD), the coping strategies questionnaire-catastrophizing scales (CSQ-CAT), and the chronic pain coping inventory-short form (CPCI-SF). Measures that assess the outcomes of psychotherapy have the potential to inform quality improvement efforts and bring greater accountability to the delivery of mental healthcare. Those patients who received the group psychotherapy completed the same set of outcome measures at the end of the intervention to determine if they experienced any improvements in their symptoms and functioning.

The PEG scale score is the average of three separate numerical scales. Each scale has ratings ranging from 0 to 10. Individuals rate their pain level concerning three different areas: pain (on average), pain interference with enjoyment of life, and interference with general activities over the past week. The PGD scale is a 10 cm line, thus giving a scale score from 0 to 10. Rating 0 represents no problems and 10 represents the worst possible situation. The CSQ-CAT score is the sum of the ratings on six statements that measure negative self-statements, catastrophizing thoughts, and ideations about their pain using a 0-5 Likert scale. The CPCI-SF scale produces two scores. One is for illness-focused coping (guarding, resting, and asking for assistance) and another for wellness-focused coping (exercise/ stretching, relaxation, task persistence, seeking social support, and coping self-statements). Participants were asked to describe how many days in the past week they used each strategy to manage pain. The scores are the sum of days they used those coping skills. The quality assurance data was analyzed with paired samples t-test (one-tailed) using the Data Analysis ToolPak Excel Add on.

Findings and Next Steps. The current findings indicate a significant decrease in pain interference scores as measured by PEG. This finding is consistent with previous research studies investigating the effectiveness of CBT with individuals suffering from chronic pain, but is an inconsistent finding among Veterans. In addition, there was a significant decrease found in pain catastrophizing (maladaptive thinking) scores as measured by CSQ-CAT. This finding is consistent with previous research studies investigating the effectiveness of CBT with Veterans suffering from chronic pain. Furthermore, a significant increase in wellness-focused coping scores were found at post-intervention compared to pre-intervention as measured by CPCI-SF. This finding is consistent with previous research studies which have found that CBT creates changes in coping. These findings are not surprising, as the aim of the CBT intervention is to decrease catastrophizing thoughts and increase wellness-focused behaviors (such as relaxation). However, the current quality improvement effort did not find significant differences in pain global distress, which is consistent with previous research. A potential reason for this finding may be that Veterans who suffer from chronic pain may be a unique group of individuals due to the dualism of active duty and civilian life.

Frontline practitioners are tasked with effectively treating and managing complex biopsychosocial symptoms in a growing number of patients with chronic pain. At the same time, they are experiencing an increased need to make services more accessible and to cut down on appointment wait times. Thus, brief biopsychosocial interventions in integrated care settings are needed to optimize providers’ time without sacrificing outcomes. Group-based formats such as bCBT have demonstrated the potential to maximize limited resources while providing an additional, interpersonal, support factor, which has been found to be valuable for patients with chronic pain. The brief cognitive behavioral therapy intervention for chronic pain is an intervention that shows promise for treating the biopsychosocial symptoms of chronic pain in an overburdened healthcare system. More research is needed to better understand the change mechanisms in group-administered bCBT interventions. More research is also needed to explore how bCBT treatment outcomes vary as a function of treatment provider and specific bCBT training. Furthermore, research investigating the impact of telehealth delivery of bCBT would extend its application, especially within underserved populations (Cosio & Demyan, 2021d).

Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD

When one’s experience is pleasant, it is easy to accept it. However, if one’s experience is unpleasant, whether it be our thoughts, feelings, or physical sensations, it is adaptive in the short term to employ defense mechanisms to repress, distract, and project to avoid the unpleasantness of the moment. Conversely, one of the principal aspects of “mindfulness” is acceptance of one’s experience in the present moment. Mindfulness is an exercise in just noticing, or nonjudgmental awareness, which has been shown to have numerous biopsychosocial benefits. It is not some special mystical state, nor is it a form of relaxation.

There are several types of mindfulness-based interventions, including mindfulness-based cognitive therapy (MBCT), primary care brief mindfulness training (PCBMT), mindfulness-based exposure therapy (MBET), and other mantra-based meditation training programs. MBCT combines ideas of traditional cognitive therapies with meditative practices aimed at cultivating mindfulness. PCBMT was developed for primary-care patients with symptoms consistent with subthreshold or diagnostic-level post-traumatic stress disorder, or PTSD. MBET is a non-trauma-focused intervention which incorporates mindfulness training and in-vivo exposure. Mindfulness-based stress reduction (MBSR) is considered one of the original mindfulness-based interventions. It has been modified to be offered virtually. Importantly, MBSR has served to inform other mindfulness approaches, such as trauma-focused therapy.

Of all the mindfulness-based interventions available, the most popular is mindfulness-based stress reduction (MBSR). Jon Kabat-Zinn developed MBSR in 1979 for patients with treatment-resistant chronic pain. He adopted the Buddhist wisdom that was initially developed to help deal with the distress of long meditations, where the body experiences discomfort from being in one position for an extended period of time. Kabat-Zinn reported feeling somewhat “called to create” the intervention for patients with treatment-resistant, chronic pain. MBSR has been found to be effective at reducing the adverse impact of chronic pain from migraines, the lower back, and other mixed conditions. Specifically, MBSR has been found to increase psychological distress tolerance and to selectively alter the unpleasantness of pain. MBSR is an integrated mind-body approach. It aims to increase mindful attention in order to help patients better recognize when coping and/or pain-management skills are needed. Moreover, MBSR has also been found to be effective at reducing the adverse impact of psychological conditions, such as PTSD. This paper reviews MBSR and its impact on distress tolerance for patients with chronic pain.

Top-down versus Bottom-up Interventions. Predominately, treatment as usual is delivered through a didactic, cognitive/top-down approach such as with cognitive behavioral therapy (CBT). Its credence is that when patients are anticipating or experiencing pain, maladaptive thinking, such as catastrophizing, activates the sympathetic nervous system. The sympathetic nervous system is responsible for stimulating activities associated with the fight-or-flight response which then inhibits access to coping mechanisms stored in the frontal cortex. Essentially, patients with chronic pain do not lack coping skills, but instead lack access to the skills during sympathetic nervous system activation. While MBSR does offer top-down cognitive-based interventions, it uniquely also offers bottom-up interventions. These interventions start in the body and engage the parasympathetic nervous system. The parasympathetic system is responsible for stimulation of activities that occur when the body is at rest. Its action is described as being complementary to that of the sympathetic nervous system.

How Does MBSR Work? MBSR uses a combination of body awareness, mindfulness meditation, and movement/yoga to help people become more mindful and accepting of the present moment.

• Body Awareness – Bottom-up treatment interventions, such as MBSR, have a somatic focus and are informed by mindfulness. Mindfulness is not only the practice of paying attention to the present moment, but also of noticing information through the senses without appraisal. Attending to the physical senses helps patients gain awareness of their body and its sensations. Increased somatic awareness helps the patient notice signals of distress earlier, making it easier to intervene with coping mechanisms before feelings overwhelm thinking. Furthermore, connecting with the body also helps to desensitize catastrophic reactions to bodily sensations. This leads to better distress tolerance, a reduction in pain-related catastrophizing, and increases in wellness across several outcome variables.

• Mindfulness Meditation – In addition to somatic awareness, MBSR has a cognitive component. Mindfulness training instructs attention toward thoughts/self-talk without appraisal. Mindfulness practices assert that the self is not comprised of impermanent thoughts, but rather the self is the curious observer of the thoughts. MBSR facilitates the curious, nonjudgmental observer, and challenges the often-enmeshed relationship between thoughts and the self by encouraging a detached observation. Through this awareness, patients report increased wellness and quality of life.

• Focused attention – This is an important component of mindfulness. Focused attention is the practice of concentrating attention on one thing and noticing when attention moves from the target. Focused attention is required to notice somatic sensations and patterns of thoughts. MBSR includes exercises and trainings that aim to increase focused attention. A focus on the breath is usually the initial object of focus. Once mindful breathing has been introduced, mindfulness practices can be generalized to other behaviors and practices such as walking, eating, and even washing dishes or mowing the lawn. Further, MBSR instructs a nonjudgmental observation. Together, focused attention and nonjudgmental awareness make up the very basic components of mindfulness.

• Movement/Yoga – Research identifies the importance of movement and the breath-based yoga components in MBSR. A meta-analysis of 17 studies investigating MBSR in a sample of patients with chronic pain found that those studies which included the yoga component had favorable outcomes compared to those that did not. Theoretically, yoga is a more accessible way to introduce one-mindedness through its use of the body with movement, pose cues, and practice focusing attention in the present moment using proprioception. It can also facilitate distress tolerance through gradual exposure to poses that challenge the body. Increases in distress tolerance have been found to explain some of the effectiveness of MBSR.

Distress Tolerance and Factor Models. Distress tolerance is the ability to tolerate or withstand distressing emotional or physical states. Distress tolerance is comprised of two subtypes: physical and psychological. The subtypes from this two-factor model have been supported in the research as two separate constructs, and lower psychological distress tolerance has been found to be associated with lower physical distress tolerance. These findings suggest that psychological tolerance is an important precursor to physical distress tolerance.

Mindfulness has been found to mediate distress tolerance. Mindfulness has historically been conceptualized as two factors: focused attention and nonjudgmental awareness. More recently, research has suggested an alternative four-factor model of mindfulness. The four factors include:

1. being accepting/non-reactive;

2. maintaining awareness of the present moment;

3. describing the experiences; and

4. being open/non-avoidant.

An investigation into the four-factor model found that both relativity of thought, which is the recognition of thoughts as ever-changing, and the acceptance subscales of mindfulness, mediate distress tolerance. The recognition of the importance of relativity of thought is consistent with Kabat-Zinn’s description of detached observation, whereby the patient aims to watch thoughts wax and wane, seeing them as separate from the self instead of misidentifying often negative thoughts as part of the self. Furthermore, a study investigating the impact of MBSR on Type D (distressed) personality dimensions found that mindfulness mediated improvements in negative affect and social inhibition.

Using MBSR with Distressed Populations. There are limits on the generalizability of research findings in the literature to special populations. Select populations have undergone more distress than the general population, such as with many Veterans. The Veteran population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities of PTSD and chronic pain, and barriers to treatment. Thus the demand for complementary and integrative health within the Department of Veterans Affairs (VA) exceeds supply, such as time, space, funding, and staff training. Traditionally, MBSR is very resource-intensive, requiring certified instructors, 2.5-hour sessions, and a daylong retreat. Past research has also shown that when one group member fails to benefit from treatment or leaves prematurely due to dissatisfaction, others in the group are likely to follow. These behaviors could be due to issues with the therapeutic alliance, but may highlight issues with the flexibility of the intervention. Considering the needs and resources available and concerns about attrition, one may implement an MBSR intervention similar to the sample delineated below.

The Pain MBSR Group is 1.5 hours/week for eight weeks and is co-led by a psychologist trained in MBSR and a trainee. Groups are comprised of six to eight Veterans who suffer from PTSD and chronic pain. Using a group format makes the intervention more time-efficient for providers, provides a mechanism for patients to learn coping skills from others, helps patients realize they are not alone, and helps patients gain valuable social support from others. There is no daylong retreat with this protocol, which is a deviation from the traditional model.

Limitations of MBSR

It is true that MBSR may be an alternative method of treatment for physicians to consider which may help their patients cope with diseases, such as PTSD and chronic pain. However, the effectiveness of MBSR and its follow-up data has been inconclusive at times. There are several explanations for these findings. First, problems with retention and time commitment have been identified as potential reasons. These two concerns can be addressed, as done by the protocol delineated above, through reducing the time by one hour/week and removing the daylong retreat.

Other researchers speculate that the inconsistency among MBSR instructors contribute to the discrepancies found in research. Kabat-Zinn also highlights the need for an MBSR instructor who does more than follow a manualized delivery, but who also embodies the “essence” of MBSR. It may be that mindfulness practice done by instructors is like physical fitness in that both need regular practice to be maintained. Evidence supports a dosage effect in that more practice is related to greater gains. Instructors who practice mindfulness may also serve as models for this behavior.

Longitudinal RCTs will result in a better understanding of the impact of MBSR on distress tolerance. They may also help to determine the impact of group versus individual delivery, instructor influence, and movement versus non-movement based MBSR interventions. More research is also needed using MBSR with more underserved populations, especially those who are low-SES, women, LGBTIQ+, and/or Black and Indigenous People of Color (BIPOC). Future studies should investigate the impact of longer-term interventions that help develop lasting lifestyle changes, while considering accessibility and ease of delivery within an often overburdened healthcare delivery system (Cosio & Demyan, 2021e).

Comorbid Chronic Pain and PTSD Using Integrated Cognitive Behavioral Therapy

The prevalence rate of chronic pain in the general U.S. population ranges between 10% and 20%. Chronic pain has been found to commonly coexist with posttraumatic stress disorder (PTSD) symptoms. In the Veteran population, the prevalence of PTSD has been found to be between 10% and 47% among those referred to a pain clinic or attending a multidisciplinary chronic pain center. Patients with comorbid chronic pain and PTSD have been found to endorse more negative belief-based and behavioral symptoms compared to patients with chronic pain only. They have also been found to be at greater risk for negative coping, such as with substance and alcohol use. These findings support the need for tailored treatment interventions for patients with comorbid chronic pain and PTSD. Consequentially, theory-supported treatment programs have evolved over time to meet the unique needs of patients with comorbid chronic pain and PTSD.

Posttraumatic Stress Disorder Defined. In order to understand the best treatment practices utilized with comorbid chronic pain and PTSD, the proper assessment of PTSD is crucial. The definition of PTSD has broadened since the release of the DSM-5 in 2013. The diagnosis now includes traumatic events that were experienced directly, indirectly, witnessed by the individual, or experienced by a family member or friend. In addition to these experiences, the individual must also exhibit symptoms from four different clusters, including reexperiencing, arousal, avoidance, and persistent negative alterations in cognitions and mood. PTSD can be diagnosed accurately by a trained mental health professional. The gold standard assessment is the Clinician Administered PTSD Scale for the DSM-5 (CAPS-5), which employs an interview with the patient about trauma and PTSD symptoms. PTSD has been found to affect 10% of women and 5% of men at some stage. However, the prevalence rates of PTSD in victims of trauma have been reported to approach 100%.

Physical health problems (cardiovascular, headaches, diabetes, respiratory, gastrointestinal, and musculoskeletal) have been shown to be more common among individuals suffering from PTSD. Studies examining the prevalence of chronic pain in individuals with a primary diagnosis of PTSD have reported even higher co-prevalence rates. The rate of chronic pain in patients who suffer from PTSD is approximately double that of the general population. Pain is the most common physical complaint among patients who suffer from PTSD. Research has shown that anywhere from 60% to 80% of Veterans with PTSD report that they have a chronic pain condition.

Comorbidity of the Conditions. When PTSD and chronic pain are considered together, the prevalence among returning Veterans has been found to be 16.5%. Earlier studies reported a 1.7% prevalence of PTSD among chronic pain patients. However, in a more recent study, 47% of a sample of Veterans with chronic pain met criteria for PTSD. Further, the prevalence of PTSD among injured workers who were referred to a rehabilitation program was found to be approximately 35%. Further, comorbid prevalence rates have been found to range between 30% and 50% among patients whose pain is secondary to a motor vehicle accident. Moreover, the prevalence of PTSD among hospitalized burn patients has been found to be approximately 45% at 12-months post injury. These two conditions may interact in such a way as to negatively impact the course of either disorder, requiring thoughtful assessment and reflexive, tailored treatments.

Individuals with this comorbidity report health problems with increased functional impairment, greater frequency and higher pain ratings. Research indicates that patients with chronic pain related to trauma or PTSD experience more affective distress, higher levels of life interference, and greater disability than their counterparts without trauma or PTSD. They further report decreased occupational functioning, including more frequent absenteeism and greater loss of productivity. More importantly, they demonstrate higher rates of healthcare service utilization and increased healthcare costs.

Understanding Pain and PTSD. There are several theories that may help explain the high rates of comorbid chronic pain and PTSD. For example, the theory of shared vulnerability proposes that underlying mechanisms, such as anxiety sensitivity, are implicated in the comorbidity. Another theory, the mutual maintenance hypothesis, proposes that cognitive, affective, behavioral (e.g., avoidance), and physiological symptoms of both disorders react in a synergistic way. Both chronic pain and PTSD share the clinical features of fear and avoidance, which may influence the development of each condition over time, may serve to maintain them, and may interact in ways that impact the outcome of either condition in a feedback loop.

The fear-avoidance model is generally acknowledged for diagnosing and understanding how humans adaptively and maladaptively react to fear. In the realm of chronic pain, the model describes how individuals develop chronic, musculoskeletal pain as a result of avoidant behavior based on fear. The fear-avoidance model states that negative appraisals about pain and its consequences, including catastrophic thoughts, can result in feelings of pain-related fear, avoidance of daily activities, and hypervigilance or over-monitoring of bodily sensations. As a result of this misinterpretation, the individual repeatedly avoids the pain-inducing activity and will likely overestimate any future pain from such activity. In turn, the avoidance response ultimately results in physical deconditioning, depression, disability from work, inability to participate in recreation, and incapacity for family activities. This perpetuates the pain experience, as opposed to moving toward wellness. Once the avoidant behavior is no longer reinforced, the individual exits the positive feedback loop.

There is evidence that fear-avoidance is closely related to increased pain, physical disability, and long-term sick leave in chronic pain patients. This does not mean that the patient is “faking it” or that “it’s all in their head.” Rather, it demonstrates the importance of the mind/body connection in symptom expression and the power of formerly learned coping strategies which were once functionally adaptive. However, in avoidance-coping, patients miss the opportunity to test the untested hypothesis: Does avoidance really keep me safe? With support and guidance, providers can gently encourage small, slow gains.

According to this model, treatment recovery is facilitated when pain acceptance is promoted. Pain acceptance increases when an individual uses adaptive coping mechanism while minimizing or neutralizing negative thoughts or beliefs about pain, and/or pain catastrophizing. This approach can be expanded to include PTSD and can provide a comprehensive explanatory framework for the conceptual, symptomatic, and behavioral overlap of the two conditions.

Treatment Modalities. There are three primary approaches to treating patients who present with both chronic pain and PTSD. First, the parallel model treats each disorder at the same time but with separate medical teams who may or may not collaborate. As a result, the treatment teams may be operating from different philosophies of treatment without knowing it. Treatment using this model often leaves patients with little or no comprehensive help, as people are often not eligible for multiple services at the same time or no one provider wants to take responsibility.

Next, the sequential model is historically the most common model of comorbid treatment. In this model of treatment, the patient is treated by two separate medical teams, with one treating one disorder and then the other team treating the other condition sequentially. This model may be problematic in that the untreated disorder may worsen the treated disorder. Also problematic is that treatment teams may disagree as to which disorder should be treated first. Further, the patient may be left with an untreated disorder at times due to a lack of follow-through by providers and/or patients in implementing the referral to the second medical team.

Lastly, the most promising model is a combined, or integrated multidisciplinary model. The integrated model is relatively new, but it has been demonstrated as an effective method in many scientific studies. This treatment model helps patients recover by simultaneously offering treatment for comorbid disorders, treating both chronic pain and PTSD simultaneously, in the same setting, with providers working collaboratively and/or with providers who have expertise in both chronic pain and PTSD.

Multidisciplinary Treatment. A multidisciplinary treatment approach to pain has been found to be the most effective method for patients with comorbid chronic pain and PTSD. Several of the more common causes of chronic pain include traumatic events; thus, it is not unusual for patients presenting with chronic pain to also describe significant levels of distress, including PTSD. The multidisciplinary treatment model should emphasize helping patients draw links between the traumatic event and subsequent chronic pain and PTSD.

Psychotherapy has been found to be the most effective therapy for patients with comorbid chronic pain and PTSD. Cognitive behavioral therapy (CBT) is a structured, time-limited, present-focused approach to psychotherapy that helps patients engage in an active coping process aimed at changing maladaptive thoughts and behaviors that can serve to maintain and exacerbate the experience of both chronic pain and PTSD. Patients have demonstrated benefits from CBT techniques (exposure therapy, pacing, and activity-scheduling) to alleviate both conditions. CBT interventions have been associated with significantly greater improvements in maladaptive coping responses to pain than wait-list controls. The current literature also reveals robust evidence that CBT is effective for PTSD. CBT can help with restructuring both the maladaptive thinking aforementioned and unhealthy behaviors to become more adaptive.

Treatment Protocol. When chronic pain and PTSD symptoms co-occur, it is likely that providers will need to modify treatment protocols accordingly. One such integrated protocol was developed by Otis and Keane in 2009 at the VA Boston Healthcare System. Their therapist’s manual combines traditional CBT with cognitive processing therapy used in PTSD treatment and is divided into twelve 60-minute sessions. The protocol begins by helping patients become aware of the links between chronic pain and PTSD symptoms. In addition, cognitive therapy strategies address attentional biases, challenge overestimation of probability and cost, reinforce positive pain self-efficacy beliefs, and challenge catastrophizing. Furthermore, the manual includes strategies aimed specifically at reducing anxiety sensitivity using interoceptive exposure. The protocol then aims to increase activity levels through the use of activity pacing, and then ends focuses on reducing cognitive and behavioral avoidance through the use of in vivo and imaginal exposure surrounding specific belief systems. Some scholars have argued that concurrent treatment of chronic pain and PTSD that is underway in the Veteran population may also be beneficial to nonmilitary/nonVeteran populations (Cosio & Demyan, 2021f).

Implementation and Dissemination

Monitoring Mental Health in Pain Management

Why Every Practitioner Needs to Monitor. The COVID-19 pandemic has unearthed a serious unmet need for better recognition and treatment of common mental health concerns in patients with chronic pain. Public health emergencies tend to affect the health, safety, and well-being of both individuals and communities, which may then translate into a range of emotional reactions and unhealthy behaviors. Extensive research in disaster-related mental health has established that emotional distress is pervasive in affected populations, particularly people with preexisting medical, psychiatric, or substance use conditions. Thus, prevention efforts such as mental health monitoring, psychoeducation, and psychosocial support should be part of any healthcare plan.

Frontline practitioners are typically faced with patients suffering from chronic pain and an undiagnosed mental health disorder when providing pain management. Individuals who suffer from pain and are diagnosed with a mental disorder have been found to experience a worsening of psychiatric symptoms. Patients are less likely to recognize or monitor comorbid medical conditions compared to the general population. They have an increased likelihood of experiencing conditions that cause pain and a lower probability of receiving adequate care.

If these conditions remain untreated, patients who suffer from mental health conditions and chronic pain may experience an impairment in their recovery, greater functional incapacitation, lower quality of life, and an increased risk for suicide compared to individuals without pain. Even when pain management is part of an individual’s treatment plan, it is important to monitor their mental health functioning. A recent study from the Department of Veterans Affairs presented in 2018 at the National Rx Drug Abuse and Heroin Summit showed preliminary data on how mortality among those individuals who were prescribed opioids occurred more among those with mental illness and/or substance-use disorder diagnoses.

Healthcare professionals may fail to give complaints about physical health problems serious consideration among patients with serious mental illness. Historically, the majority of mental health cases in most cultures have gone unrecognized in primary care settings. About 60% of previously undetected cases could have been recognized if the patients had been evaluated for the mental health disorder. Past research has shown that patients attending pain specialty clinics tend to have more intractable pain conditions, comorbid psychiatric disorders, use more outpatient services, and receive a greater number of opioid prescriptions. These data support the inclusion of mental health monitoring as part of pain management.

Which Mental Health to Monitor. Research shows that many individuals are reluctant to seek in-person healthcare due to fear of contracting COVID-19, raising the concern that mental health and pain conditions will progress to more advanced disease. According to the National Alliance on Mental Illness, roughly 44 million American adults are affected by mental illness. Mental illness is distress and dysfunction that negatively affects someone’s thoughts, emotions, and/or behaviors and interferes in their ability to live a full life in society. The DSM-5 is the most widely used resource for the diagnosis of mental disorders. It provides a set of criteria for classification and diagnosis of numerous mental disorders. Numerous studies have documented a strong association between mental health and chronic pain. Previous research has shown that chronic pain is most often associated with depression, anxiety, somatoform, personality, and substance-use disorders.

How to Monitor Mental Health. Opportunities to monitor the mental health of individuals who suffer from chronic pain and to deliver support directly in clinical practice has been greatly curtailed due to COVID-19. Psychosocial services are increasingly being delivered in primary care settings by means of telemedicine. The key to providing better care during this pandemic lies in making services available and ensuring patients seek help when necessary. In fact, the Centers for Disease Control and Prevention has released guidance on the expanded use of telehealth services. The Substance Abuse and Mental Health Services Administration has also strongly recommended the use of telehealth to provide evaluation and treatment of patients.

During these times, psychosocial assessment and monitoring should include queries about COVID-19-related stressors, secondary adversities (economic loss), psychosocial effects (such as depression, anxiety, psychosomatic preoccupations, and increased substance use), and indicators of vulnerability (preexisting conditions). It is important now more than ever to use reliable, evidence-based tools for rapid screening and comprehensive assessment, remote and online administration, and progress-monitoring.

• Depression – The Beck Depression Inventory, the Center for Epidemiological Studies-Depression Scale, the Geriatric Depression Scale, and the Patient Health Questionnaire (PHQ-9) are just a few examples of measures providers can use. Remember, monitoring for depression includes suicidal and homicidal behavior.

• Anxiety – The Beck Anxiety Inventory and the anxiety scales of the Brief Symptom Inventory are the most commonly recognized measures. Other measures may be better measures of general distress, such as the State-Trait Anxiety Inventory, or measures of specific diagnoses, such as the Mobility Inventory (agoraphobia) or the Penn State Worry Questionnaire (worry in generalized anxiety disorder).

• Somatoform – Inventories that measure somatization as defined in the past include the Minnesota Multiphasic Personality Inventory-Hypochondriasis Scale and the Rating Scale for Somatic Symptoms. Other useful scales include the Symptom Checklist-90-R (broad range of psychological symptoms), the Illness Behavior Questionnaire (attitudes, affects, and attributions related to illness), the Illness Attitude Scale (hypochondriacal fears and beliefs), the Primary Care Evaluation of Mental Disorders (physical symptoms), the Whitney Index (hypochondriasis), the Health Attitude Survey (dissatisfaction with health and distress), and the Somatosensory Amplification Scale (sensitivity to bodily sensations).

• Personality – The more widely used measures are the Myers-Briggs Type Indicator, Neo Personality Inventory-Revised, 16-Personality Factor, Millon Clinical Multiaxial Inventory, the Schedule for Nonadoptive and Adaptive Personality, the Temperament and Character Inventory, and the Eysenck Personality Questionnaire. In addition to self-report inventories, there are many other methods for assessing personality, including observational measures, peer-report studies, and projective tests, such as the Thematic Apperception Test or ink blots (Rorschach). The most widely used objective test of personality is the Minnesota Multiphasic Personality Inventory-2.

• Substance-Use – Urinalysis remains the standard means of testing for drug use. Several instruments are available for the measurement of alcohol use, including the Alcohol-Use Inventory, the Alcohol Dependence Scale, the Michigan Alcoholism Screening Test, the Addiction Severity Index, the Alcohol Use Disorders Identification Test (AUDIT-C), and the CAGE questionnaire. Evaluations should also include consideration of use of Medically Assisted Treatment to treat opioid use disorder.

• Lifestyle – An assessment may include inquiries about physical activity levels, weight and BMI/abdominal girth, nutrition, dental care, sexual activity, and sleep hygiene. These queries can be achieved using biometric screenings and virtual check-ups offered at home.

Additional information can be provided by screening required for specific medications (lithium carbonate, valproic acid, carbamazepine, antipsychotics, and mood stabilizers). Thanks to telehealth and mobile technology, providers can track behavioral, physiological, and social signals that are relevant to mental health states. For example, providers can take notice and document changes in speech patterns, technology use, facial expression, eye movement, and communication patterns during their telehealth encounters.

Providers should also inquire and document important information about the cultural, religious, and spirituality components of an individual’s life to gain a better understanding of the patient’s point of view. The types and timing of support that may be lacking in an individual’s life may also be important aspects to consider. These surveys can be completed by patients alone on their own time or with the assistance from an assessor.

Real-World Mental Health Monitoring Scenarios. The COVID-19 pandemic has alarming implications for the emotional and social functioning of an individual and the collective health of the general population. In addition to providing medical care, frontline providers have an important role in monitoring psychosocial needs and delivering psychosocial support to their patients.

Providers can begin implementing psychosocial monitoring by first asking their patients who suffer from chronic pain how they are feeling and coping with the COVID-19 pandemic. Are their patients exhibiting any unusual behaviors, such as being withdrawn, having anger outbursts, having lower thresholds for tolerance of social interactions, and/or isolating? Have the patients had any thoughts of self-harm/suicide? Remember to also inquire about their lifestyle, such as checking their sleeping and eating patterns. The following three cases highlight common scenarios that may arise in monitoring mental health as part of pain management:

Scenario 1: Patient is endorsing mental health symptoms and is in need of support.

A 55-year-old male patient suffering from chronic pain has initiated an appointment to speak to a pain provider via telehealth during the pandemic. Before meeting the provider virtually, he was asked to complete the Brief Symptom Inventory. The anxiety scales from the measure indicate the patient may be suffering from some distress. This is coupled by the patient’s presentation (anger, poor social interactions, isolation) and self-report about difficulties sleeping and eating during the COVID-19 pandemic. The pain provider concludes that the patient could benefit from supportive counseling, but the patient is stating they are worried about having any face-to-face interactions at this time. Frontline providers may want to be familiar with mobile apps that can provide resources. It may also benefit the provider to have an electronic newsletter, blog, or offer webinars specific to managing stress associated with COVID-19.

Scenario 2: Patient is currently taking psychotropic medication for their mental health.

A 45-year-old transgender patient suffering from chronic pain is speaking to their pain provider via telehealth during the pandemic. During the initial chart review, the frontline provider noticed that the patient is currently prescribed a benzodiazepine by another provider. As part of their assessment, the frontline provider has determined the patient continues to suffer from anxiety using information they gathered via the Beck Anxiety Inventory and changes they observed during their virtual exchange (heart rate and mobility). They also look into their chart to see the results of their last urinalysis to determine if benzodiazepines were present. The frontline provider may further query the other provider or access the prescription drug monitoring program to confirm. This information will impact the frontline provider’s decision about whether to initiate an opioid as part of the patient’s pain management plan.

Scenario 3: Patient is currently under the care of a mental health provider.

A 34-year-old female patient suffering from chronic pain is speaking to their pain provider via telehealth during the pandemic. As part of their assessment, the frontline provider has inquired about the patient’s depressive symptoms, completed the Beck Depression Inventory, and has amassed evidence from their virtual exchange (changes in speech patterns and facial expression) to determine that they may also be suffering from depression. The frontline provider is not aware whether the patient is seeking outpatient mental health services at this time. Upon inquiry, the provider can determine a course of action. If the patient is under the care of a mental health provider, then the frontline provider may query about the treatment care plan, if the patient is willing to share it. If not, then the provider may ask for permission to contact the current mental health team to plan continuing support. The provider may also offer information about a 24/7 crisis support line staffed by trained mental health professionals. If the patient is endorsing suicidal thoughts, then the provider should get local emergency services involved (Cosio, 2021).

Relapse, Noncompliance, and Adherence Enhancement

According to the World Health Organization, approximately 125,000 people with treatable diseases die each year in the U.S. because they do not take their medication as prescribed. In addition, the WHO also reports that 10% to 25% of hospital and nursing home admissions result from patient noncompliance. Furthermore, adherence rates for behavioral change related to obesity, substance abuse, smoking cessation, and chronic pain have shown similar relapse rates following completion of treatment. Even clinical trials report average adherence rates of only 43% to 78% among patients receiving medication for chronic conditions. These statistics underline a major issue we continue to face in this country with treatment adherence and relapse. This section will define these terms and will offer providers evidence-based strategies, such as building the therapeutic relationship, motivational interviewing, and health-coaching interventions, to help maintain long-term gains in their pain-management care.

Defining the Terms

Noncompliance. Approximately 2/3 of the 750 million new prescriptions written each year will undergo partial or complete noncompliance. About 70% of patients will drop out of psychotherapy by the third session. In fact, noncompliant behavior is likely one of the most common causes of treatment failure for chronic conditions, though this is not widely or consistently recognized. The term compliance is the extent to which a patient’s behavior concurs with the advice given by a healthcare provider. Past research has shown that approximately 1/3 of patients can be expected to be noncompliant, and regimens that are more demanding can be expected to have lower compliance rates. In fact, patients who suffer from chronic pain frequently get discouraged with extended medical treatments that produce limited therapeutic results and become less compliant over time.

There are several potential consequences of noncompliance, including exacerbation and progression of disability, development of complications which lead to medical emergencies, and escalation and/or failure of treatment. Traditionally, providers have used the terms intentional and unintentional noncompliance, which contrast whether failure to follow advice is due to memory problems, lack of understanding, and/or inadequate explanation by a healthcare provider. Providers have moved away from using these terms as they imply a prejudicial attitude toward the patient that assumes they alone are at fault for the failure. One useful article makes a number of practical suggestions for addressing noncompliance, including simplifying medication regimens, providing rewards and recognition for the patient’s efforts, and enlisting social support from family and friends.

Nonadherence. Most of the literature investigating nonadherence is centered around medications. Results from one study showed that about 23% of patients avoid using their pain medication, 13% alter dosages, and 10% stop taking their medications. However, the incidence of nonadherence also includes other behaviors. For example, about 50% to 60% of patients fail to keep appointments for preventative programs and 30% to 40% fail to keep appointments for curative regimens. In addition, more than 50% of patients with chronic noncancer pain are nonadherent with their prescribed exercise treatment. The term adherence is used to imply a more active, voluntary, collaboration with the patient in a mutually acceptable course of behavior to produce a desired result. We often forget that patients have an autonomous right to make bad decisions about their healthcare. It is important to note that patients may also exhibit variable adherence rates for different aspects of treatment and/or at different times. Past research has identified variables that might be related to nonadherence, including demographic, incentive, attitude, and psychological variables (e.g., denial, depression, dementia, cultural issues, and substance abuse), but does not support being correlated to a single factor. Instead, a more multivariate perspective is considered to be associated to nonadherence, which results from an interaction of several factors, including:

• Inherent features of the treatment regimen: such as the complexity (e.g., treatment costs), intrusiveness (e.g., unpleasant side effects), and duration of the treatment and knowledge of the illness;

• The therapeutic environment: includes organizational structure, scheduling of appointments, continuity of care, and length of referral and wait times;

• Characteristics of the disease or injury: such as recognizability of the illness and unpleasantness of the symptoms;

• The patient-provider relationship: includes approachability, shared medical decision-making, amount of provider supervision, trust, and mutual respect; and

• Characteristics of the patient: such as prior experiences, feelings of uncertainty, inconvenience, pessimism, and other patient beliefs.

Due to the breadth of this topic, there have been many different measures developed and different criteria employed for the assessment of adherence. One criterion proposed is that a minimum standard is necessary to be set to achieve a desired health benefit. Adherence is generally measured as a continuum and should not be considered all-or-nothing. Investigators have recommended the use of multiple indicators of adherence, including:

• Self-report measures: may be the easiest to obtain, the most frequently used, and easy to implement (e.g., interviews and self-monitoring);

• Behavioral measures: the most common method is medication adherence (e.g., pill counts or refills), activity levels (e.g., pedometers and actometers), and attendance of sessions;

• Biochemical indices: less subject to bias, but may be more expensive, not available, and vulnerable to metabolic conditions; and

• Clinical outcomes: suggested to be the best way, but there is no linear association; may also involve independent observers (e.g., family and friends).

Providers can formulate specific procedures for improving patient participation, such as anticipating nonadherence, considering the prescribed self-care curative measures from the patient’s perspective, improving the patient-provider relationship, customizing treatment, enlisting family support, and making use of other health care providers.

Relapse. Treatment success is usually suggested when 30% to 70% of patients maintain gains over a one-year to five-year period. However, this statistic also means that 30% to 70% of patients will not witness improvement from treatment. Moreover, research has shown that approximately 1/3 of originally successful patients will relapse. The term relapse implies that any improvements after a treatment have regressed, or evaporated, to pre-treatment baselines. A general question providers ask is why do some patients who show initial treatment success relapse? Research has indicated that it is less about individual characteristics, such as personality, compensation, and/or psychopathology, and more having to do with long-term maintenance or skills. Some investigators have used increasing the length of treatment, adding booster sessions, and focusing on high-risk situations that foster decline, but these strategies do not appear to resolve the issue of relapse. Instead, research has shown that the chances of a relapse can be reduced if the skills learned are generalizable, translatable to the patient’s life, and continuously reinforced. As a field, we should be exploring treatments that enhance generalization rather than just evaluating the effectiveness of different modalities.

Maintaining Long-Term Gains.There are evidence-based strategies that providers can use to help maintain long-term gains in their pain management care, including building the therapeutic relationship, motivational interviewing, and health-coaching interventions. Traditionally, an authoritarian approach was used in medicine, but has since been transformed toward a collaborative partnership between the patient and the provider that is based on mutual goals, a shared understanding (about the importance of the medical problem, the availability of effective treatments, and the risks if the problem remains untreated or undertreated), and the potential solutions. The therapeutic relationship, or therapeutic alliance, is a common factor in psychotherapy identified by Grencavage and Norcross. Therapeutic relationship factors are characteristics of the provider and the patient that facilitate change and are present regardless of the type of intervention. One must keep in mind, however, that government health programs and private payers have adopted various reforms that fundamentally transform this relationship. For example, public reporting and payment reforms incentivize providers to improve the quality and efficiency of care they provide to patients, but may also induce providers to reject patients who do not abide by their medical opinion. Despite these barriers, there are several different strategies providers can use to build the relationship, including employing empathy, warmth, respect, genuineness, acceptance, encouragement, instruction, and communication. For example, communication skills that utilize a nonjudgmental tactic, openly explore the patient’s beliefs and concerns, and negotiate a plan using shared medical decision-making are crucial. Research has shown that participating in a brief communication skills training has improved outcomes in primary care settings for patients with fibromyalgia and acute pain.

Another technique that may be used to help maintain long-term gains in the patient’s pain-management care is motivational interviewing (MI). MI was developed in the early 1980s in the treatment of persons with addictive behaviors, such as alcohol abuse, smoking, and opiate use. MI is a patient-centered, directive technique, aimed to improve the motivation and commitment of patients to achieve behavioral changes. The spirit of MI includes collaboration, respect for autonomy, and elicitation. There are also four main principles to use when applying MI: expressing accurate empathy, developing discrepancy, avoiding argumentation and rolling with resistance, and supporting self-efficacy. MI principles are now being applied to the management of chronic conditions, such as chronic pain. This technique has been shown to have an effect on chronic pain patients maintaining their compliance with exercises for coping with pain.

Health coaching interventions have also been reported to improve health outcomes for individuals with chronic diseases, such as chronic pain. Health coaching interventions, commonly referred to as life coaching, health coaching, or wellness coaching, lack definitional clarity which has made it difficult to study and compare coaching interventions. Health coaching is a patient-centered approach where patients use self-discovery combined with educational content to work toward their desired goals and self-monitor their behaviors to increase accountability with a coach. There are several features common to nearly all forms of coaching, including the core assumption that people have an innate capacity to grow, a focus on building solutions, and a focus on goal attainment (Cosio & Demyan, 2020e).

Improving Access to Care Through Choice

A general conclusion about the treatment of chronic, noncancer pain is that the results from research studies are disheartening. Of all the treatment modalities currently available, the best evidence for pain reduction averages around 30% in about half of treated patients. In other words, one could only expect a person suffering from chronic, noncancer pain reporting a 9 on the Numeric Rating Scale to see maybe a 3 point reduction in their severity score, half of the time. Clinical trials have indicated the comparable efficacy of numerous diverse treatment interventions – acupuncture, behavioral therapy, exercise therapy, and nonsteroidal anti-inflammatory (NSAIDs) – for chronic, noncancer pain. Overall, the current evidence provides little support for choosing one approach over another. Here is a brief look into each type of pain-management modality and its corresponding research. Each section is followed by a case description that encourages the reader to question what else may be accounting for the change being witnessed.

Pharmacological Treatments. Medication management will continue to be the mainstay of chronic pain treatment in the future. The classes of drugs most commonly used for the treatment of chronic, noncancer pain are opioids, NSAIDs, antidepressants, anticonvulsants, muscle relaxants, and topical agents. Meta-analyses concluded that opioids result in small improvements in pain severity and function compared with placebo. The efficacy of NSAIDs has been established for some patients with pain (arthritis, back), but has not been investigated in others (neuropathic pain, fibromyalgia). Meta-analyses also suggested that antidepressants result in moderate symptom reduction and are superior to placebo. The best evidence supports the efficacy of anticonvulsant drugs (gabapentin, pregabalin, and carbamazepine) for the treatment of chronic noncancer pain. Muscle relaxants are typically recommended as adjuvant therapy and seem to have a restricted role in chronic pain. Topical agents have also been shown to effectively reduce chronic pain in comparison to placebo.

Sample Case #1:

A 68-year-old, Caucasian man comes to the pain clinic for the first time reporting neck and lower back pain, which he has suffered from since the 1960s after several car accidents. The patient discusses at length all the various opioids he has been on throughout the years and how he has repeatedly been able to “wean myself off” them. The patient is in the pain clinic hoping that a 30 day supply of fentanyl patches could be prescribed for pain since he expects that the opioid should help, considering his past history. Is it the medications alone that accounted for the outcome(s) in the past or is something else happening in this case?

Interventional Treatments. Interventional pain medicine involves the application of various techniques, such as injections, surgery, and implantable devices. Epidural steroid and facet injections are the most commonly used in the U.S.; however, the evidence for epidural steroid injection use as long-term monotherapy is not clear. Facet injections have some evidence for use with facet joint pain, but are not clearly effective for other syndromes. In terms of surgery, evidence has rated lumbar fusion as “fair,” and both discectomy and laminectomy as “good,” with the proviso that significant pain can persist even after spinal surgery. Several meta-analyses evaluated the efficacy of spinal cord stimulation and concluded that there was moderate evidence for improvement in pain. A more recent systematic review evaluated the efficacy of epidural and intrathecal drug delivery systems, and determined that there were moderate reductions in pain, but the long-term effectiveness remains unclear.

Sample Case #2:

A 69-year-old, Caucasian man comes to the pain clinic after having a medial branch block (MBB) for arthritis in the joints of his spine about six months ago. MBB is a diagnostic injection that temporarily – for a couple of hours – interrupts the pain signal being carried from a specific facet joint, providing relief. If the MBB proves to be successful, then a radiofrequency nerve ablation, where radio frequency waves are used to produce heat on specifically identified nerves surrounding the facet joints, may be performed. The patient reports that he continues to have relief from the MBB, which is similar to the outcomes he has had in the past with other injections. The relief from the MBB should have only lasted a couple of hours. Was it the injection/procedure alone that accounts for the outcome or is something else happening in this case?

Physical Medicine and Rehabilitation Approaches. Evidence suggests that exercise can effectively decrease pain and improve function, but no conclusions can be made about exercise type. Physical medicine approaches are commonly included as components of interdisciplinary pain rehabilitation programs – the embodiment of the biopsychosocial model. The reduction of pain after treatment at an interdisciplinary pain rehabilitation program has been reported to be significant.

Sample Case #3:

A 68-year-old, African-American man suffering from the early stages of Parkinson’s disease comes to the pain clinic in a motorized wheelchair, accompanied by his son. Since he has been coming to the pain clinic, he has had physical and occupational therapy at home, which he and his son feel has made a significant improvement in pain, strength, and coordination. The patient has exhausted the 12 sessions covered by his insurance, but is now requesting further visits at home. He is asking if it can be approved due to barriers including his son’s other responsibilities as a father. Was it the physical and occupational therapy alone that accounts for the outcome or is something else happening in this case?

Psychological Approaches. Psychological treatment as a whole results in modest improvements in pain and physical and emotional functioning, but there is insufficient evidence to recommend one therapeutic approach – behavioral therapy, cognitive behavioral therapy, psychodynamic therapy, stress management, emotional disclosure, biofeedback, and hypnosis – over another. Interestingly, the modest reductions in pain severity witnessed with psychological interventions were similar to those noted with pharmacological, interventional, physical, and rehabilitative approaches.

Sample Case #4:

A 58-year-old, African-American woman comes to the pain clinic diagnosed with pseudo-gout and fibromyalgia. She’s in a wheelchair and there is a cast on her right knee. She notes that she “hurt my knee so people would pay attention” to her verbal complaints. She completes a course of treatment, including cognitive behavioral therapy for pain, and acceptance and commitment therapy, and seems to be coping with her pain better. Every time she sees her provider, she exclaims, “There is my favorite doctor” and goes in for a hug. Was it the psychotherapy alone that accounts for the outcome or is something else happening in this case?

Complementary and Integrative Health (CIH) Approaches. Complementary and integrative health (CIH), formerly known as complementary and alternative medicine (CAM), is a group of medical and healthcare systems, practices, and products that can be categorized into four general categories: mind-body medicine (biofeedback, hypnosis, and yoga), natural-biological based (aromatherapy and herbs), manipulation/body-based (chiropractor, massage, and spinal manipulation), and energy medicine (acupuncture and healing touch). There is promising scientific evidence to support the use of CIH/CAM for noncancer pain conditions, such as low back pain (cognitive behavioral therapy, exercise, interdisciplinary rehabilitation, massage, spinal manipulation, progressive relaxation, yoga, acupuncture, and functional restoration); osteoarthritis (acupuncture, tai chi, self-management programs, and walking aids); rheumatoid arthritis (omega-3 fatty acids, relaxation, mindfulness meditation, tai chi, and yoga); headaches (relaxation training, biofeedback, acupuncture, and spinal manipulation [dietary supplements are also promising]; preliminary support for fibromyalgia (tai chi, qi gong, yoga, massage therapy, acupuncture, and balneotherapy); promising support for irritable bowel syndrome (hypnotherapy and probiotics); and limited support for neck pain (acupuncture and spinal manipulation).

Sample Case #5:

A 62-year-old, Caucasian woman has been coming to the pain clinic for about a year and has tried all the different modalities available, without any relief. The patient has a history of multiple traumas and has suffered two strokes. The current provider introduces her to a nurse who is similar characteristically to her and who has been trained in healing touch. The patient returns a month later and notes that the healing touch is the only thing that has worked for her and that she enjoys working with the nurse. Was it the healing touch alone that accounts for the outcome or is something else happening in this case?

Choosing a Treatment. Providers may consider several factors when choosing a treatment for pain:

• Pain related factors: type and intensity of pain, physical, cognitive abilities, and concurrent symptoms;

• Individual related factors: previous experiences, expectations for outcome, cultural and spiritual influences, patient preferences and coping styles; and

• Environment factors: involvement of friends and family.

Thus, providers try different treatments until they find something that works. Research has shown that the overall treatment effectiveness for chronic pain remains inconsistent and fairly poor. The practice of psychotherapy confronted a similar issue, deciding which approach to choose over another, in the past. The field of pain management may be able to glean insight from the psychological research literature in “common factors.”

Common Factors Model. References to the concept of “common factors” in psychotherapy began as early as 1936. At that time, research studies were concluding that all psychotherapies were effective. It wasn’t until 1952, when Eysenck announced his refutation that psychotherapy does not lead to improved patient outcomes, that research into the efficacy of psychotherapy witnessed a resurgence. Several meta-analyses illustrated the absolute efficacy of psychotherapy. Two important findings have been noted from those analyses: 1) Improved research methods did not increase the effects found, and 2) Effect sizes were comparable across all treatments.

These conclusions led to the distinction of two possible mechanisms of psychotherapeutic change, “specific” vs. “nonspecific” effects. Specific effects were associated with unique interventions to certain therapy approaches, while nonspecific effects were linked to contextual factors of the clinical encounter. Evidence from systematic reviews of diverse psychotherapy interventions indicate that factors common across therapies contribute more to treatment outcomes than effects associated with specific technical interventions. Meta-analytic studies then summarized psychotherapy outcome research and reduced the factors into four areas:

• Client factors – the characteristics of the patient and his/her environment were found to explain 40% of the variance in outcomes.

• Therapeutic relationship – 30% of the variance in outcomes was attributed to the therapeutic relationship, the characteristics of the provider and the patient that facilitate change and are present regardless of the type of intervention.

• Expectancy/placebo/hope – 15% is explained by expectancy/placebo/hope.

• Techniques/models – 15% is explained by the techniques/models we use.

This research later inspired a book titled The Great Psychotherapy Debate, which concluded that nonspecific effects were responsible for more than four times the amount of variance in treatment outcomes across various interventions. Using models developed in other professions (in this case psychotherapy) to inform inquiry in another field is appropriate, and there is some precedence in the literature, specifically in physical medicine and rehabilitation. Is it possible that these nonspecific effects are responsible for some amount of variance in treatment outcomes in pain management?

Common Factors in Pain Management. “Common factors” speaks to pain management being an art form in addition to a science. From a psychotherapy perspective, specific interventions, such as the techniques/models discussed previously – pharmacological, interventional, physical medicine and rehabilitation, psychological, and CIH CAM approaches – will not be fully effective without the contribution from the other common factors. There is evidence to suggest that these same common factors may be responsible for general effects in pain management.

Patient Factors. Patient factors are characteristics of the patient and their environment. Several different themes were explored when investigating more than 20 retrieved articles on patient factors: remission, inner strength, resiliency, goal directedness, purpose, motivation, personal agency, sense of control, fortuitous events, by chance, social support, faith, life experiences, strengths and abilities, and readiness to change. Themes such as social support, faith, and strengths/abilities seemed to have more literature related to them than others such as motivation, whose model of pain management was only recently developed. In summarizing the findings from the various studies, it would appear that treatment outcomes were better when the patient:

• Was employed, which affected remission;

• Had high treatment outcome expectations;

• Was resilient and remained positive;

• Was engaged in activities that were purposeful;

• Was motivated to manage pain;

• Had an internal locus of control;

• Felt they had control over their pain;

• Perceived having social support;

• Believed in god or a spiritual power greater than themselves;

• Did not experience any recent/daily life stressors;

• Had positive beliefs and used coping strategies; and

• Had an increased readiness for change.

Therapeutic Relationship Factors. The therapeutic relationship, or working alliance, is a psychotherapy common factor identified by Grencavage and Norcross (1990). Therapeutic relationship factors are characteristics of the provider and the patient that facilitate change and are present regardless of the type of intervention. Several different themes were explored when investigating approximately 25 retrieved articles on therapeutic relationship factors: empathy; warmth; respect; genuineness; acceptance; encouragement; and instruction, communication, and the patient-provider relationship. Themes such as the patient-provider relationship and encouragement/instruction seemed to have more literature than other themes. In summarizing the findings from the many examinations, it would appear that:

• Provider empathy plays a crucial role in pain treatment;

• Providers who are warm are more effective;

• Patients are more satisfied when they perceive they are respected by providers;

• Patient suffering may be affected by acknowledgement of genuineness of pain;

• Patients need to reframe treatment as acceptance of chronic pain;

• Patient encouragement and instruction decreases pain and increases satisfaction;

• The communication process influences self-management of pain; and

• The patient-provider relationship is significantly associated with outcome.

Expectancy Factors. Expectancy factors are improvements that result from the patient and provider’s belief that treatment is effective. Several different themes were explored when investigating almost 20 retrieved articles on expectancy factors: expectations; placebo; noncompliance; relapse; optimism; hope; and credibility. Themes such as expectations seemed to have the most literature available. In summarizing the results from numerous investigations, it would appear that treatment outcomes were enhanced when:

• Patients expect and believe treatment is potentially beneficial;

• Providers consider how placebo effects and regression to the mean improve outcomes;

• Providers consider the patient’s potential to be noncompliant and relapse;

• Patients are optimistic, have hope, and/or accept their pain; and

• Patients feel providers believe their pain is credible.

Sociocultural Factors. Sociocultural factors are the larger scale forces within cultures and societies that affect the thoughts, feelings, and behaviors of individuals. Sociocultural factors related to the pain experience may include pain expression, pain language, lay remedies for pain, social roles, tangibles, and perceptions of the medical care system. In summarizing the findings from the examinations, it would appear that:

• Dissimilarities in cultural views about the mind-body relationship affects patient’s pain;

• Tangibles can be barriers to patient self-management;

• The needs of pain management providers cannot be ignored; and

• Using a patient-centered approach improves self-rated pain and physical mobility.

Ethical and Legal Factors. Effective pain management has been deemed a right to health according to international human rights law. Thus, inadequate pain treatment is considered a violation to protect against cruel, inhuman, and degrading treatment. In summarizing the findings from the examinations, it would appear that:

• Narratives of patient perception note pain as being a “moral event”;

• Providers may alter their practice in response to patient expectations; and

• It is difficult to support this position as a point of law or as a matter of ethics.

Revisiting Case Samples

Throughout this section, a question was posed: Is it the technique alone that accounted for the outcome or “Is something else happening in this case?” In Case #1, a 68-year-old man is asking for a 30-day supply of fentanyl patches for his pain since it helped in the past. In this example, one should consider the impact of the technique being used: pharmacology. However, one should also consider the impact of the expectations of the patient and any patient factors, such as the potential that the patient is suffering from an opioid use disorder. It is less likely that there is an impact from the therapeutic relationship since this patient is new to the pain clinic.

In Case #2, a 69-year-old man comes to the pain clinic after having had a medial branch block MBB for arthritis in the joints of his spine about six months earlier, and he continues to have relief from the procedure despite the fact that it was intended to last only a few hours. Again, one should consider the impact of the technique being used: the intervention or injection/procedure. However, one should also consider the impact of the expectations of the patient and the therapeutic relationship – the patient has had multiple injections/procedures in the past and has built a relationship with the pain clinic team.

Case #3 involved a 68-year-old man suffering from early stages of Parkinson’s disease, requesting additional home physical and occupational therapy sessions beyond what has been approved by his insurance company – an expectancy. Note: he came to the pain clinic in a motorized wheelchair accompanied by his son, both facts which indicate that the patient may struggle with independence – a patient factor. Physical therapy and rehabilitation exercises, the technique/model, have been shown to be effective, but require that the patient continue them at home independently. Continuing to offer the technique at home may continue the dependence and be effecting the outcome.

In Case #4, a 58-year-old woman comes to the pain clinic diagnosed with pseudo-gout and fibromyalgia. She’s in a wheelchair, with a cast on her right knee. There are clear patient factors present in this case as there is evidence of characterological issues including self-harm (she hurt her knee to prove she’s in pain). The patient also appears to have developed a strong therapeutic relationship with her therapist, her “favorite doctor,” beyond the techniques. There is also clear evidence for the need to set appropriate boundaries in this case.

In Case #5, a 62-year-old woman has been coming to the pain clinic for about a year and has tried all the different modalities available without any relief, but then finds healing touch to be “the only thing that worked.” In this example, one should consider the impact of the technique being used – the CIH/CAM approach. However, one should also consider the impact of the therapeutic relationship with the provider, a nurse who is similar characteristically to the patient. The patient may have been more comfortable with this particular provider due to their similar interests and her history of traumas. There is also the possibility that the patient had hoped this technique would help since it was referred to her by the pain clinic team (Cosio, 2016).

The Role of Telemedicine in Pain Management

Due to the advent of COVID-19, the field of medicine has had to reconsider how to use telecare as an option for healthcare in America. Behavioral medicine has been using telecare for some time, partly to address the shortage of mental health professionals in the U.S. but also because research has found that virtual mental health counseling is at least as effective, if not more so, than traditional face-to-face sessions. While telecare was still in its infancy, mental health professionals were among the first adopters of this practice – including myself. I was first introduced to telecare at the beginning of the new millennium during my graduate career at Ohio University while working in a HIV/AIDS research laboratory. Telecare proved to be such a great tool to reach such an audience, that I used it on my own dissertation entitled, A Telephone-Delivered, Motivational Interviewing Intervention to Reduce Risky Sexual Behavior in HIV-Infected Rural Persons: A Pilot Randomized Clinical Trial. I have also used videoconferencing for groups and pain education programming during my career as a psychologist at the U.S. Department of Veterans Affairs (VA), which has been leading the way in telehealth innovation to make sure Veterans can access high-quality care. There are several lessons we have learned about telecare throughout the years, including some negative (e.g., using new technology and reimbursement) and positive effects (e.g., convenience, accessibility, and cost-effectiveness). The purpose of the current review is to offer some help for new providers to move beyond face-to-face consultation and consider new ways to deliver their care.

Negative Effects of Telecare. The first thing to consider is the logistics and considerations that come along with using telecare. Telecare can be provided using several different types of technology, including the telephone, videoconferencing, and video platform messaging/apps (e.g., Facetime, Zoom, WebEx, WhatsApp, Google Duo, and Viber). The provider needs to be knowledgeable about the equipment and technologies they are using. For example, for videoconferencing, I might use a 42-inch plasma television connected to Tandberg Codec C40s. The Tandberg Codec C40 provides all the power required to transform any room into a 1080 HD video multimedia presentation. The codec is a device, either hardware- or software-based, that encodes analog video/audio signals to digital video/audio, and vice versa. Use of PowerPoint or other information can be displayed as needed when using the technology in groups or programming.

The provider will inherit several roles when using telecare. They will not only be responsible for the consultation itself, but they may also need to coordinate the appointments. This includes promoting telecare services; contacting and scheduling patients; completing patient encounters; and transferring materials to patients when needed. Providers may also need to maintain communication and troubleshoot with a telehealth technician who is credentialed and privileged. Such a relationship may require a telehealth service agreement, which defines the responsibilities and procedures involved in establishing and operating a telehealth clinic. The telehealth technician provides technical support for providers to ensure clinical efficiency and effectiveness during a telecare visit, such as ensuring there is adequate technology infrastructure, bandwidth, technical troubleshooting, and support.

Providers need to be aware of their state’s policies and the internal rules in their place of employment and whether they will receive reimbursement for services they provide via telecare. One of the tricky things about telecare is that each state has different policies and requirements for how telemedicine should be practiced. This may require the provider to do a little research on what their state medical board requires. Secondly, they will need to do a bit of research into third party payer’s guidelines for telemedicine if they want to bill through a patient’s insurance. For example, Medicare expanded telemedicine coverage for seven mental health services in 2015. Since then, many insurance companies and telemedicine providers have followed suit by encouraging telecare for mental health.

The clinical documentation of the event is very important as with any medical visit, intervention, or encounter. Telecare visits need to be documented and notes should include all pertinent information. Workload can be captured using encounter data and clinic designation. The creation of encounter forms, progress notes, and consult templates for telecare visits are also essential. To ensure the provider and their facility receives accurate workload reports, and to evaluate the economic and other impacts of the telecare programs, sources such as a data warehouse and virtual-care-modality report can be used to verify accurate workload credit. Yet, a third consideration should be whether the provider’s malpractice coverage covers them for telecare. While telecare can tax the skills of even the most experienced providers, it is necessary, and perhaps even desirable, for several reasons.

Positive Effects of Telecare. Past research has shown that there are several positive outcomes (e.g., improvements in mortality, quality of life, and reductions in hospital admissions) when using telecare for remote patient monitoring for several chronic conditions (e.g., cardiovascular and respiratory disease) and for psychotherapy as part of behavioral medicine. There are few studies, however, on the application of telemedicine to chronic pain patients. A study by Peng and colleagues (2006) was the first pilot project to determine that telemedicine technology for chronic pain consultation was feasible, cost-saving, and satisfactory to patients and pain physicians. There is also research to show that using telecare for pain education programming found no significant difference between face-to-face and telecare interventions on patients’ stage of readiness to adopt a self-management approach, their experience of pain, and its impact on their depressed mood.

Both providers and patients can experience numerous benefits to virtual care. Telecare provides ease and convenience to users who may simply need a computer, webcam, and broadband internet access to provide care via video platform messaging/apps. Telecare may also establish a potentially cost-effective way to reach patients who have difficulty accessing services. Vast geographic distances, limited transportation, and physical disabilities preclude many patients who suffer from pain from traveling to face-to-face appointments. Telecare can circumvent the costs and inconveniences associated with geographic distances between practitioners and patients, reduce costs associated with travel and lodging, and impose less of a physical strain on the patient’s health. When using telecare, patients are less likely to miss appointments since they can meet from their location. The industry average for missed appointments is approximately 30% to 40%. However, with telecare the average no-show rate has been shown to drop down to about 3.5%. Despite some providers reporting some loss of the interpersonal benefits of face-to-face consultations, telecare offers an effective alternative especially during a time where stay-at-home orders are implemented. Therefore, providers should execute best practices for conducting telecare which occur either before or during the meeting.

Best Practices and Etiquette. When using telephone technology, one practical adaptation that can be made is to increase the use of verbal check-ins during a meeting. For example, if a patient is silent for several seconds, the provider might ask “How do you feel about what I just said?” or “Is there something you are thinking about right now?” Verbal check-ins can be used to better engage patients in the meeting and ensure they are not distracted by persons or events in their environment.

There are different practices a provider needs to exercise when using videoconferencing and video-platform messaging/apps. Before each meeting, it is the responsibility of the provider (and/or the clinical technician if applicable) to check the room to ensure the seating arrangement will allow the provider to be properly viewed, to make sure all media (PowerPoints, audio, and video clips) are fully functioning, and to troubleshoot the equipment or video-platform messaging/apps at least 30-45 minutes ahead of the scheduled appointment. To avoid having technical difficulties and to ensure success of the telecare meeting, it is important to build close relationships with the support staff (such as room schedulers and biomedical electronic services if conducted from a facility). These relationships are oftentimes overlooked and are actually necessary for a telecare encounter to be realized.

Conducting a successful videoconference either through technical equipment or video platform messaging/apps also requires a certain level of etiquette. The following are ten tips that all types of physicians can use during telecare, whether it’s their first time or they are using it regularly:

1. The provider wants to be sure to be dressed appropriately and that they are conducting the meeting in a professional space.

2. The provider needs to make sure the microphone remains muted until the videoconference starts or until someone in the meeting wants to speak (if using it for groups or programs).

3. The provider may need to assist their patient(s) in adjusting their screens, volume, and environment to guarantee a successful meeting

4. The provider should initiate the meeting punctually and start by introducing themselves (and allowing time for others to introduce themselves during groups or programs).

5. During the meeting, the provider needs to make sure they look into the camera when speaking.

6. The provider should speak in a normal tone and slow their speaking pace slightly to accommodate split-second delays when transmitting over long distances.

7. The provider should avoid noisy activities (e.g., tapping a pen or whispered side conversations) which can affect the clarity of the transmission.

8. The provider should allow approximately 5-10 minutes before the end of the encounter to answer any questions.

9. The provider should make sure to review important items and confirm the next appointment date and time. At the conclusion of the meeting, the provider may wish to inquire about their patient’s experience with the telecare visit (Cosio, 2020b).

 

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References

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Cosio, D. & Demyan, A. (2021e). Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD. Practical Pain Management, July/August, 21 (4).

Cosio, D. & Demyan, A. (2021f). Comorbid Chronic Pain and PTSD: An Update on Research and Treatment. Practical Pain Management, November/December, 21 (6).

Cosio, D. & Meshreki, L. (2017a). The Association Between Depressive Disorder and Chronic Pain. Practical Pain Management, January/February,17(1).

Cosio, D. & Meshreki, L. (2017b). Anxiety and Pain. Practical Pain Management, April, 17(3).

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