02. August 2022
“It’s all psychological!” is what patients with chronic pain have to hear over and over again for months or years. Although the statement is not particularly empathetic, there is a grain of truth in it. Every pain sensation originates in the mind, and there are countless factors that determine whether and how long it lasts. Cognitive behavioral therapy (CBT) addresses these very factors and gives hope to sufferers who often experience rejection and feel powerless as doctors fail to find effective treatment options.
If you hold your hand too close to a burning candle or get too close to the iron you’ve plugged in, you immediately flinch reflexively. The mechanism of pain makes us recognize dangerous situations immediately and our body reacts with fight or flight. However, if the pain loses its warning function and lasts longer than three months or significantly exceeds the normal duration of an illness, we speak of chronic pain. In contrast to acute pain, it does not indicate damage to the body (e.g. an injury), but represents a disease in its own right, often without an identifiable cause. Those affected by chronic pain have an altered pain processing system that independently generates signals through changes at the neuronal level. Accompanying symptoms are often complaints such as lack of appetite, sleep problems, depressive mood and irritability.
Important: In Germany, between eight and sixteen million people suffer from chronic pain. The most common forms are headaches, back pain, joint pain and fibromyalgia syndrome.
The causes of chronic pain can be very diverse. Simplified, they can be divided into three areas:
Accompanying symptom of a physical disease: chronic pain can occur in the course of diseases such as rheumatism, osteoporosis, arthrosis or nerve damage. Phantom limb pain from an amputation also falls into this category.
Comorbid pain with a physical and psychological trigger: This includes pain due to tissue damage that is aggravated by concurrent psychological factors. An example is back pain from a herniated disc that is exacerbated by depression or an anxiety disorder.
Primary psychological triggers: Here, chronic pain occurs in the course of, for example, persistent conflicts in the social environment or at work, post-traumatic stress disorders, depression or even anxiety disorders. The stress manifests itself in various parts of the body, such as the muscles of the back, the gastrointestinal tract or even the chewing muscles.
Internal compulsions and an unfavorable pain processing can let chronic pain manifest and maintain itself in the body. For example, if we have pain in our back due to poor posture, thoughts such as, “I need a time out” would be appropriate as well as the action of actually taking a break. The dysfunctional wanting to persevere (“Now don’t get in line, there will be a break later”), trivializing (“It’s not that terrible”), and ignoring exacerbate the pain. In the course of unfavorable pain processing, people experience chronic pain as particularly threatening and fall into an absolute protective posture. They avoid any physical activity and are in a state of constant fear. Catastrophizing any bodily sensations and associated thoughts again intensifies chronic pain. In addition, there is a kind of pain memory. When pain stimuli recur, the body “remembers” them, even if the cause is no longer present. Subsequent pains are processed more quickly and perceived more strongly due to the more sensitive pain memory. A vicious circle. Affected persons focus on the pain, which causes anger and fear, for example, and in turn intensifies the perception.
Psychotherapy cannot cure the physical illness portion of a pain disorder, but it can work on how to deal with it and the psychological sequelae. Some psychotherapeutic methods already exist for treating chronic pain, with cognitive behavioral therapy being one of the most effective. In CBT, patients learn strategies to cope with stress and change their behavior so that it does not further exacerbate pain. Likewise, by providing sufficient information about the main pain mechanisms and their effects, the aim is to relieve the anxiety of the sufferers. This requires the following steps:
A situation analysis enables the identification of dysfunctional thoughts and behaviors. In the course of this, typical situations in which the pain becomes stronger are identified and analyzed. How does the patient behave in the situations, what does he think and feel? In the context of self-observation and pain diaries, possible courses of action for coping with pain are identified.
These are to be formulated very concretely as favorable thoughts and behavioral ironies. So that the fear of change is not too great, they are defined in small steps and realistically achievable. It is also crucial for the patient to feel in control and to be able to take the steps at his or her own pace. Only in this way can the treatment measures be accepted and integrated into everyday life in such a way that, in the best case, they are maintained for life.
New behaviors are first practiced in role plays. This allows us to test how difficult it is to implement them and whether they suit the patient. “Homework” for implementation in everyday life is also part of cognitive behavioral therapy. Depending on the physical condition, physical activity, concentration exercises or a regular exchange with acquaintances can also bring relief. Likewise, the evaluation of the pain can be worked on and thus control over the body can be regained.
How effective psychotherapy is for chronic pain depends largely on its causes. Especially if the causes are of a purely physical nature, psychotherapy cannot replace drug treatment. However, it can help to divert thoughts away from the pain and to re-evaluate it. The associated strengthening of the social environment and activities can enormously increase the well-being and form the foundation for a new concept of life. Psychotherapy should thus always be a building block on the way to treating chronic pain.