Operant-behavioural and cognitive-behavioural treatment for chronic low back pain.

Fifty-eight outpatients with chronic low back pain were randomly allocated to one of six experimental conditions. Four conditions were designated as treatment conditions and two as control conditions. The four treatment groups consisted of: cognitive treatment (either with or without relaxation training) and behavioural treatment (either with or without relaxation training). The cognitive and behavioural groups also received physiotherapy. The two control conditions consisted of: attention (physiotherapy plus discussion sessions) and no-attention (physiotherapy-only) conditions. All conditions, including the two controls, received the same physiotherapy back-education and exercise program. For the sample as a whole, improvements were obtained on measures of affective distress, functional impairment, medication use, pain-related dysfunctional cognitions and use of active coping strategies. These improvements were generally maintained at 6- and 12-month follow-ups. The combined psychological/physiotherapy treatment conditions improved significantly more than the physiotherapy-only conditions from pre to posttreatment on measures of pain intensity, self-rated functional impairment and pain-related dysfunctional cognitions. However, these differences were only weakly maintained at 6- and 12-month follow-ups. The behavioural conditions improved significantly more than the cognitive conditions from pre to posttreatment on the self-rated measure of functional impairment, but this difference was not maintained at 6- and 12-month follow-ups. Progressive relaxation training was found to make little contribution to either cognitive or behavioural treatments.     

Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy

There are now numerous studies of Acceptance and Commitment Therapy (ACT) for chronic pain. These studies provide growing support for the efficacy and effectiveness of ACT in this context as well as for the role of ACT-specific therapeutic processes, particularly those underlying psychological flexibility. The purpose of the present study was to continue to build on this work with a broader focus on these processes, including acceptance of pain, general psychological acceptance, mindfulness, and values-based action. Participants included 168 patients who completed an ACT-based treatment for chronic pain and a three-month follow-up. Following treatment and at follow-up, participants reported significantly reduced levels of depression, pain-related anxiety, physical and psychosocial disability, medical visits, and pain intensity in comparison to the start of treatment. They also showed significant increases in each of the processes of psychological flexibility. Most uncontrolled effect sizes were medium or large at the follow-up. In correlation analyses changes in the four processes measures generally were significantly related to changes in the measures of depression, anxiety, and disability. In regression analyses the combined processes were related to changes in outcomes above and beyond change in pain intensity. Although in some ways preliminary, these results specifically support the unique role of general psychological acceptance in relation to improvements achieved by treatment participants. The current study clarifies potential processes of change in treatment for chronic pain, particularly those aiming to enhance psychological flexibility.     

Acceptance and values-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process

Recent developments in CBT emphasize the promotion of psychological flexibility to improve daily functioning for people with a wide range of health conditions. In particular, one of these approaches, Acceptance and Commitment Therapy (ACT), has been studied for treatment of chronic pain. While trials have provided good support for treatment effectiveness through follow-ups of as long as seven months, the longer-term impact is not known. The present study of 108 participants with chronic pain examined outcomes three years after treatment completion and included analyses of two key treatment processes, acceptance of pain and values-based action. Overall, results indicated significant improvements in emotional and physical functioning relative to the start of treatment, as well as good maintenance of treatment gains relative to an earlier follow-up assessment. Effect size statistics were generally medium or large. At the three-year follow-up, 64.8% of patients had reliably improved in at least one key domain. Improvements in acceptance of pain and values-based action were associated with improvements in outcome measures. A “treatment responder” analysis, using variables collected at pre-treatment and shorter term follow-up, failed to identify any salient predictors of response. This study adds to the growing literature supporting the effectiveness of ACT for chronic pain and yields evidence for both statistical and clinical significance of improvements over a three-year period.     

Integrating Pain Management in Clinical Practice

There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. In this paper, we briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain.     

A Couple-Based Psychological Treatment for Chronic Pain and Relationship Distress

Chronic pain impacts individuals with pain as well as their loved ones. Yet, there has been little attention to the social context in individual psychological treatment approaches to chronic pain management. With this need in mind, we developed a couple-based treatment, “Mindful Living and Relating,” aimed at alleviating pain and suffering by promoting couples’ psychological and relational flexibility skills. Currently, there is no integrative treatment that fully harnesses the power of the couple, treating both the individual with chronic pain and the spouse as two individuals who are each in need of developing greater psychological and relational flexibility to improve their own and their partners’ health. Mindfulness, acceptance, and values-based action exercises were used to promote psychological flexibility. The intervention also targets relational flexibility, which we define as the ability to interact with one’s partner, fully attending to the present moment, and responding empathically in a way that serves one’s own and one’s partner’s values. To this end, the intervention also included exercises aimed at applying psychological flexibility skills to social interactions as well as emotional disclosure and empathic responding exercises to enhance relational flexibility. The case presented demonstrates that healthy coping with pain and stress may be most successful and sustainable when one is involved in a supportive relationship with someone who also practices psychological flexibility skills and when both partners use relational flexibility skills during their interactions.     

Cognitive factors influence outcome following multidisciplinary chronic pain treatment: a replication and extension of a cross-lagged panel analysis

Reducing maladaptive cognitions is hypothesized to constitute an active therapeutic process in multidisciplinary pain programs featuring cognitive-behavioral interventions. A cross-lagged panel design was used to determine whether: a) early-treatment cognitive changes predicted late-treatment pain, interference, activity and mood changes, but not vice versa; b) three cognitive factors made unique contributions to outcome; c) substantial cognitive changes preceded substantial improvements in outcome. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary program, completed measures of pain helplessness, catastrophizing, pain-related anxiety (process factors), pain severity, interference, activity level and depression (outcomes) at pre-, mid- and posttreatment. Results showed that early-treatment reductions in pain helplessness predicted late-treatment decreases in pain and interference, but not vice versa, and that early-treatment reductions in catastrophizing and pain-related anxiety predicted late-treatment improvements in pain severity, but not vice versa. Findings suggested that the three process factors predicted improvements mostly in common. However, little evidence was found that large early-treatment reductions in process variables preceded extensive improvements in pain. Findings replicate those of a recent report regarding cross-lagged effects, and offer support that cognitive changes may indeed influence late-treatment changes in outcomes.     

抑制功能在疼痛中的作用

自生物心理社会模型提出以来, 利用心理因素预防和治疗疼痛备受关注, 越来越多的研究表明抑制功能在疼痛发展和恢复阶段起关键作用。疼痛诱发的自我防御机制通过争夺认知资源影响抑制功能, 反之低抑制功能个体在应对疼痛干扰中表现较差, 进而影响着疼痛的预期和学习。现有关于抑制功能影响疼痛的研究主要基于相关设计, 未来应进一步明确二者的因果关系。深入理解疼痛与抑制功能相互作用的认知机制有助于指导抑制功能对慢性疼痛的靶向干预。     

Pain anxiety, acceptance, and outcomes among individuals with HIV and chronic pain: a preliminary investigation

The current study investigated the role of during treatment changes in pain anxiety in the relation between during treatment changes in pain acceptance and chronic pain outcomes. Participants included 45 (15 women) adults (M_age = 50.42, SD = 7.69) who were HIV positive and experienced chronic pain. They were offered 12 weekly, 90-min group CBT sessions to increase understanding about chronic pain and to improve coping skills. Four hierarchical regression analyses were conducted to examine the mediating role of treatment changes in pain anxiety in the relation between treatment changes in pain acceptance and chronic pain outcomes. Results suggest that increases in pain acceptance during treatment were associated with decreased levels of pain anxiety during treatment, as well as decreases in pain-related impairment at treatment completion. Furthermore, decreases in pain anxiety during treatment were associated with decreases in pain-related impairment at treatment completion. Finally, treatment changes in pain anxiety were found to partially mediate the association between treatment changes in pain acceptance and pain-related impairment at treatment completion. Results are discussed within the context of better understanding the processes of change within a CBT model for chronic pain patients.     

Processes in acceptance and commitment therapy and the rehabilitation of chronic fatigue

Acceptance and commitment therapy (ACT) has never been tested for patients with chronic fatigue. We aimed to test if a 3.5‐week ACT rehabilitation program for patients with chronic fatigue improved quality of life (QoL), fatigue, and psychological flexibility. Further, to test if improvements in QoL and fatigue were associated with improvement in psychological flexibility, and if psychological flexibility explained variance above and beyond maladaptive cognitions typically targeted in CBT for fatigue. Patients (n = 140) who had been on sick leave > 8 weeks due to chronic fatigue received a 3.5‐week non‐controlled inpatient rehabilitation program based on ACT. A physician and a psychologist examined the patients, assessing medication use and SCID‐I diagnoses. Patients completed questionnaires about somatic complaints, psychological complaints, and maladaptive cognitions before and after treatment. At post‐treatment, patients reported improved QoL (p < 0.001; g = 1.07) and less fatigue (p < 0.001; g = 1.08), but not increased psychological flexibility (p = 0.6). Changes in psychological flexibility was associated with improved QoL, but not fatigue, in hierarchical regression analyses. When adjusting for other cognitions, changes in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility, were associated with improved QoL and fatigue. The ACT‐based treatment improved QoL and reduced fatigue for patients with chronic fatigue with large effect sizes. Improvement was associated with a reduction in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility.     

The Moderating Effect of Cognitive Flexibility in the Relationship Between Work Stress and Psychological Symptoms in Korean Air Force Pilots

Stress is closely associated with not only physical illness but also with indices of psychological maladjustment. However, such negative mental health outcomes may vary depending on the individual’s cognitive style, or perception of stress. Air force pilots are particularly vulnerable to experience a high degree of stress as they are required to conduct missions while simultaneously monitoring for safety in complex and uncertain flight situations. It can thus be posited that appropriate use of cognitive stress management strategies is one of the crucial competency requirements for pilots. As such, the present study examined the effects of stress on psychological symptoms of Korean Air Force pilots and further investigated the moderating role of cognitive flexibility in this relationship. A total of 192 air force pilots participated in the present study. The results indicated that degree of stress was positively correlated with indices of psychological maladjustment, while cognitive flexibility was negatively associated with psychological symptoms. Furthermore, cognitive flexibility demonstrated a significant moderating effect on the relationship between stress and psychological symptoms. Such results suggest that cognitive flexibility may serve as a protective factor in the potential effects of stress on psychological adjustment. Implications and suggestions for future research are discussed.     

Is running a state of mind? Sports training as a potential method for developing cognitive flexibility

The study aimed to test the significance of sports participation as a potential means of improving cognitive function, particularly cognitive flexibility. Based on the characteristics of orienteering, such as frequent changes of behavioural strategies in response to changes in the situation or the simultaneous performance of several mental activities, we assumed that practising this sport could foster the development of cognitive flexibility. Two groups of volunteers were compared: 50 middle and long-distance runners and 50 orienteering runners in terms of their performance on the following measures of cognitive flexibility: a divergent thinking task, a computer flexibility task, Cognitive Flexibility Scale, and Verbal Fluency Test as a measure of executive function. Orienteering runners outperformed others on all measures except the Cognitive Flexibility Scale. Furthermore, we found that training characteristics (regularity, frequency, participation in competitions) were associated with levels of cognitive flexibility, particularly among orienteering runners, where they explained between 38% and 39% of the overall flexibility variance. Our results suggest that cognitive flexibility can be developed through sports training requiring effective dealing in a changing, complex environment. We also discuss the implications of our results for cognitive training research.     

An Evaluation of Two Types of Cognitive Intervention in the Management of Chronic Tinnitus

Abstract

Fifty-four subjects with chronic distressing tinnitus were randomly allocated to one of four experimental treatment conditions: (1) attention control and imagery training (AC1); (2) cognitive restructuring (CR); (3) combined attention control and imagery training plus cognitive restructuring (ACI + CR); and (4) a waiting list control (WLC). Significant overall improvements were found on measures of distress associated with tinnitus, and on a number of other measures of cognition and coping strategies. These improvements were maintained at the six-month follow-up. Relative to the WLC, the three treatment conditions (combined) were associated with improvements in tinnitus-related distress, reductions in tinnitus-related dysfunctional cognitions and an increase in the frequency of use of coping strategies. There was a significant effect in favour of the ACI group compared to the CR group on the measure of irrational beliefs. The analyses also revealed that the combined treatment condition (ACI + CR) showed significantly greater improvement on a measure of psychological distress and achieved a higher clinical response rate compared to the two single treatments. There were significant improvements from pretreatment to follow-up on some measures, although the mean scores revealed that some of the gains had been lost at this stage on the main measure of tinnitus-related distress. There were no significant group X time effects for any of the dependent variables at the six-month follow-up. The results were interpreted as supporting the practice of combining the two cognitive approaches.     

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.     

Differential effects of avoidant and attentional coping strategies on adaptation to chronic and recent-onset pain

Examined the effectiveness of attentional and avoidant coping strategies for somatic, behavioral, and psychological adaptation to clinical pain. Subjects were 30 chronic and 30 recent-onset pain patients who used either attentional or avoidant coping strategies in response to their pain. Based on a review of the coping literature, it was hypothesized that subjects with recent-onset pain would demonstrate greater adaptation (lower anxiety, depression, lower pain severity and somatization ratings, and higher levels of social activity) when employing avoidant rather than attentional strategies. Chronic pain subjects using attentional strategies were predicted to demonstrate greater adaptation than chronic pain subjects using avoidant strategies. The results supported this "time x strategy" hypothesis. Implications for pain treatment programs are discussed, and suggestions are made for matching pain duration with patient coping style.     

Beyond opposites: Extending the cultural boundaries of CBT methodology

In cognitive behavioural therapy (CBT), a black or white perception of the world is generally considered to be a distortion of reality. This paper addresses the issue of bipolar or categorical thinking and its role in creating disturbance. It introduces a new quantitative methodology known as fuzzy logic (FL) and shows its potential in developing new effective CBT strategies to address bipolar thinking. The paper maintains that the roots of such thinking can be traced back to the Aristotelian logic which posits a 'black or white' view of the world. It is argued that a bipolar perspective is no longer defendable given recent developments in the field of literature, physics and logic. Moreover CBT can derive significant benefits by embracing the fuzzy logic paradigm. In particular it can, first, benefit by improving the degree of precision of its diagnostic tools and, second, by applying the FL principles to derive alternative strategies for inducing healthy changes in clients. Such improvements are believed to enhance CBT profile in terms of the degree of realism, flexibility and efficiency of its methods. The illustrations offered throughout this paper are based on the two main CBT perspectives; rational emotive behaviour therapy (REBT) and cognitive therapy (CT).     

Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash‐Associated Disorders (WAD)? A Randomized Controlled Trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash‐associated disorders were recruited from a patient organization and randomized to either a treatment or a wait‐list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10‐session protocol emphasizing values‐based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7‐month follow‐up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

Comparison of three cognitive strategies in altering pain behaviors on a cold pressor task

The efficacy of three cognitive strategies for coping with pain was examined in a cold-water pressor task in a sample of college students. Subjects were pretested and then randomly assigned to one of three treatment conditions (Paradoxical Intention, Rational Self-statement, or Self-observation) or to an expectancy control group. Following training in the respective cognitive strategies, all groups were given a posttest in the cold-water pressor to determine the effectiveness of the treatment. Pain thresholds, tolerances, and discomfort ratings were recorded for subjects in each condition. No differences were found between the Paradoxical Intention or Rational Self-statement groups and the Expectancy Control on any of the pain measures. The Self-observation treatment condition, however, had significantly higher pain tolerance scores than the Expectancy Control group. The findings were attributed to the subjects' dissociating the sensory aspects of the pain experience from the anxiety when focusing upon the coldness and wetness of the cold water.     

Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash-associated disorders were recruited from a patient organization and randomized to either a treatment or a wait-list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10-session protocol emphasizing values-based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7-month follow-up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

Follow-up results of a cognitive-behavioural treatment for chronic pain in a primary care setting

Abstract

An outpatient cognitive-behavioural treatment programme for pain control was administered to chronic pain patients in three primary care practices with a medical psychologist as a group therapist. The patients suffered from headaches, migraines, cervical pain, shoulder-arm pain, and low back pain. A matched sample of patients with the same disorders served as a waiting-list control group. The programme consisted of training in progressive muscle relaxation, several attention related techniques, and cognitive restructuring as well as reinforcing non-pain behaviour, and aimed at an improvement of self-control strategies. At the six month follow-up, the treated subjects showed improvements in their average scores of anxiety, depression and bodily symptoms compared with the untreated controls. Pain intensity was reduced by 34% in those subjects (9 out of 25) who were most adherent to the treatment regimen. Our results indicate a long-term improvement in well-being as a consequence of the treatment. This was confirmed by the ratings of the physicians and by the reduced number of patient-physician contacts three months post treatment as compared to the controls. Treatment adherence seems to be a most important agent in maintaining long-term reductions of pain intensity.     

工作记忆训练对药物成瘾者认知功能的改善及其机制

对处于戒断期的各类药物成瘾群体进行认知训练，训练后药物成瘾个体认知能力得到改善，成瘾症状也得到了一定缓解。认知训练能够加速药物成瘾者大脑受损区域的自发性恢复，尤其是使影响个体抑制控制能力的中脑边缘多巴胺系统和前额叶系统发生功能性和结构性的积极变化，实现药物成瘾个体高级认知能力的改善。今后可以从不同类别的药物成瘾是否全部具有可逆性，设置的认知训练任务能否起到改善认知能力的效果，药物成瘾个体训练的性别差异以及训练效果的保持时间等角度进行研究。