Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic.

Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as "non-primary pain") to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is "nonspecific." Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PERSPECTIVE: We developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial.

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

"I don't have chronic back pain anymore": Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain.

In a recently published randomized controlled trial, two-thirds of the patients receiving a novel psychological treatment, pain reprocessing therapy (PRT), reported elimination or near-elimination of chronic back pain. The mechanisms of PRT and related treatments remain poorly understood but are hypothesized to center on pain reappraisal, fear reduction, and exposure-potentiated extinction. Here, we investigated treatment mechanisms from the participants' perspective. A sample of 32 adults with chronic back pain who received PRT completed semi-structured posttreatment interviews about their treatment experiences. The interviews were analyzed with multiphase thematic analysis. The analyses identified 3 major themes reflecting participants' understanding of how PRT led to pain relief: 1) reappraisal to reduce fear of pain, which included guiding participants to relate to pain as a helpful indicator, overcoming pain-related fear and avoidance, and reconceptualizing pain as a "sensation;" 2) the link between pain, emotions, and, stress, which included gaining insight into these connections and resolving difficult emotions; and 3) social connections, which included patient-provider alliance, therapist belief in the treatment model, and peer models of recovery from chronic pain. Our findings support the hypothesized mechanisms of PRT centered on pain reappraisal and fear reduction, but also highlight additional processes from the participants' perspective, including a focus on emotions and relationships. This study underscores the value of qualitative research methods in illuminating the mechanisms of novel pain therapies. PERSPECTIVE: This article presents participants' perspectives on their experience engaging in a novel psychotherapy for chronic pain, PRT. Through pain reappraisal, linking pain, emotions, and stress, and connecting with their therapist and peers, many participants reported an elimination or near-elimination of their chronic back pain with therapy.

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples.

A single session of Emotional Awareness and Expression Therapy (EAET)-the EAET Interview-was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al. in Health Psychol 37(3):282-290, 2018) and tertiary care (Carty et al. in Pain Med 20(7):1321-1329, 2019) settings. There has yet to be an examination of patients' experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients' reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients' emotional processing is particularly beneficial. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.

Internet-based emotional awareness and expression therapy for somatic symptom disorder: A randomized controlled trial.

OBJECTIVE: Somatic symptom disorder (SSD) is commonly encountered in health care settings. Cognitive-behavioural treatments have been most extensively studied, but they tend to have small effects of temporary duration. Emotional awareness and expression therapy (EAET) is a newly developed treatment for SSD, targeting emotional processing of trauma and conflict as a mechanism of symptom change. In an earlier uncontrolled study of self-guided, internet-administrated EAET (I-EAET), we found substantial reductions in somatic symptoms, prompting the need for a randomized controlled trial of I-EAET. METHODS: We conducted a 2-arm RCT, comparing 10-week I-EAET (n = 37) to a waitlist control (WL; n = 37). Primary outcomes were reductions of somatic symptoms (PHQ-15) and pain intensity (BPI-4) at post-treatment, with a 4-month evaluation of effect duration. We also analysed emotional processing (EPS-25) and depression (PHQ-9) as possible mediators of I-EAET's effects. RESULTS: Compared to controls, I-EAET significantly reduced somatic symptoms at both post-treatment and follow-up. I-EAET also reduced pain, depression, insomnia, and anxiety at post-treatment, but these effects were not retained at follow-up. As hypothesized, a facet of emotional processing partially mediated the treatment effect on somatic symptoms, even when controlling for depression. CONCLUSIONS: Although treatment effects were smaller than in the previous uncontrolled trial, I-EAET is a promising treatment for SSD, with a minority of patients (around 20%) experiencing substantial clinical improvement. The benefits of I-EAET are partially mediated by improved emotional processing. Future research should identify and target patients who respond best to I-EAET and develop tailored treatment to enhance treatment effects. (Preregistered at clinicaltrials.gov: NCT04751825.).

Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial.

Importance: Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury. Objective: To test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients' beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms. Design, Setting, and Participants: This randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) and 1-year follow-up assessment was conducted in a university research setting from November 2017 to August 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020. The study compared PRT with an open-label placebo treatment and with usual care in a community sample. Interventions: Participants randomized to PRT participated in 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. Treatment aimed to help patients reconceptualize their pain as due to nondangerous brain activity rather than peripheral tissue injury, using a combination of cognitive, somatic, and exposure-based techniques. Participants randomized to placebo received an open-label subcutaneous saline injection in the back; participants randomized to usual care continued their routine, ongoing care. Main Outcomes and Measures: One-week mean back pain intensity score (0 to 10) at posttreatment, pain beliefs, and fMRI measures of evoked pain and resting connectivity. Results: At baseline, 151 adults (54% female; mean [SD] age, 41.1 [15.6] years) reported mean (SD) pain of low to moderate severity (mean [SD] pain intensity, 4.10 [1.26] of 10; mean [SD] disability, 23.34 [10.12] of 100) and mean (SD) pain duration of 10.0 (8.9) years. Large group differences in pain were observed at posttreatment, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group. Hedges g was -1.14 for PRT vs placebo and -1.74 for PRT vs usual care (P < .001). Of 151 total participants, 33 of 50 participants (66%) randomized to PRT were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care. Treatment effects were maintained at 1-year follow-up, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was -0.70 for PRT vs placebo (P = .001) and -1.05 for PRT vs usual care (P < .001) at 1-year follow-up. Longitudinal fMRI showed (1) reduced responses to evoked back pain in the anterior midcingulate and the anterior prefrontal cortex for PRT vs placebo; (2) reduced responses in the anterior insula for PRT vs usual care; (3) increased resting connectivity from the anterior prefrontal cortex and the anterior insula to the primary somatosensory cortex for PRT vs both control groups; and (4) increased connectivity from the anterior midcingulate to the precuneus for PRT vs usual care. Conclusions and Relevance: Psychological treatment centered on changing patients' beliefs about the causes and threat value of pain may provide substantial and durable pain relief for people with CBP. Trial Registration: ClinicalTrials.gov Identifier: NCT03294148.

Emotional Processing and Its Association to Somatic Symptom Change in Emotional Awareness and Expression Therapy for Somatic Symptom Disorder: A Preliminary Mediation Investigation.

Objective: The aim of this study was to investigate emotional processing as a potential mediator in therapist-guided, internet-based Emotional Awareness and Expression Therapy (I-EAET) for somatic symptom disorder, using data from a previously published pilot study. Methods: Participants (N = 52) engaged in a 9-week I-EAET treatment. Before treatment and each week during treatment (i.e., 10 weekly measurements), emotional processing was assessed with the Emotional Processing Scale-25 (EPS-25), which contains five subscales, and somatic symptoms were assessed with the Patient Health Questionnaire-15 (PHQ-15). Results: Mediation analyses using linear mixed models showed that two EPS-25 subscales-Signs of Unprocessed Emotions and Impoverished Emotional Experience-were uniquely associated with somatic symptom reduction. The proportion of the mediated effect was 0.49, indicating that about half of the total association of the PHQ-15 with symptoms was accounted for by the two EPS-25 subscales. Conclusion: This preliminary mediation analysis suggests that improved emotional processing is associated with change in somatic symptoms in I-EAET. However, randomized controlled and comparison trials are needed to establish that I-EAET creates the change in emotional processing and that such changes are specific to I-EAET.

Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects.

OBJECTIVE: A recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment. METHODS: Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables. RESULTS: We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = -1.07), which was maintained at long-term follow-up (SMD = -0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = -0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders. CONCLUSIONS: STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.

Internet-Administered Emotional Awareness and Expression Therapy for Somatic Symptom Disorder With Centralized Symptoms: A Preliminary Efficacy Trial.

Background: There is growing evidence that trauma, psychosocial conflict, and difficulties with emotional processing contribute to centralized somatic symptoms. Emotional Awareness and Expression Therapy (EAET) was developed to address these factors and reduce symptoms, and EAET has shown efficacy in face-to-face formats. No trial of an internet-delivered EAET (I-EAET) exists, however, so we developed such an intervention and conducted an uncontrolled feasibility and potential efficacy trial of I-EAET for patients with Somatic Symptom Disorder (SSD) with centralized symptoms (SSD-CS). Method: After screening potential participants, a sample of 52 patients (50 women, two men; age M = 49.6, SD = 11.9) diagnosed with SSD-CS initiated treatment. I-EAET consisted of nine weekly modules focused on psychoeducation, emotional awareness and exposure, and anxiety regulation with self-compassion. Therapists communicated with each patient by email for about 20 min per week during treatment, answering questions and giving feedback on homework assignments. Patients completed measures of somatic symptoms, depression, anxiety, trauma-related symptoms, and functional disability before treatment and again at post-treatment and 4-month follow-up. Results: A large reduction in somatic symptoms (PHQ-15) occurred pre-to post-treatment (d = 1.13; 95% CI: 0.84-1.47) which was fully maintained at 4-month follow-up (d = 1.19; 95% CI: 0.88-1.56). Twenty-three percent of the patients at post-treatment and 27% at follow-up achieved a 50% or greater reduction in somatic symptoms, and about 70% achieved a minimally important clinical difference. In addition, at post-treatment, there were small to medium reductions (d's from 0.33 to 0.72) in anxiety (GAD-7), depression (PHQ-9), trauma-related symptoms (PCL-5), and functional disability (Sheehan Disability Scale). For all of these secondary outcomes, improvements were slightly to substantially larger at follow-up than at post-treatment (d's from 0.46 to 0.80). Conclusion: I-EAET appears to be a feasible treatment for adults with SSD and centralized symptoms, resulting in substantial and durable improvement not only in somatic symptoms but in other psychiatric symptoms and functioning. Controlled trials are needed determine the effects of I-EAET specifically and how this approach compares to face-to-face EAET and to other internet-delivered treatments, such as cognitive-behavioral interventions. Research should also identify treatment responders and mechanisms of change in EAET. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04122846.

Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain.

Emotional awareness (EA) is a key emotional process that is related to the presence and severity of chronic pain (CP). In this report, we describe primary and secondary emotions, discuss the distinction between emotional states and emotional regulation/processing, and summarize theory and research highlighting the significance of EA for CP. We describe ways to assess EA and diagnose centrally-mediated CP, for which emotional processes appear most relevant. We review several psychological interventions designed to enhance EA as well as several broader emotional processing treatments developed to address trauma and psychosocial conflicts underlying many patients' pain. We conclude by offering our perspective on how future integration of emotional processing into pain care could promote recovery from CP.

Effects of a Sexual Health Interview among Arab American Women: An Experimental Disclosure Study.

Although sexuality is an important aspect of peoples' health and well-being, many people-professionals and patients alike-find sexuality uncomfortable to discuss. In Arab culture, certain sexual thoughts and behaviors are taboo, particularly for women, and it is not known whether an interview in which Arab American women disclose their sexuality to a health professional would be well-received and beneficial or upsetting and harmful. This experimental study tested whether engaging in a disclosure-oriented sexual health interview affects Arab American women's sexual and psychological health. A sample of 134 Arab American women, ages 18-35 years (M = 20.6), completed self-report measures of sexual health and attitudes and psychological symptoms, and then were randomized to an interview or control (waitlist) condition. The 60-min disclosure interview inquired about sexual attitudes, experiences, and conflicts. Five weeks later, all participants completed follow-up measures. Post-interview reports suggest that participants responded favorably to the interview and generally benefited from participation. Analyses of covariance (controlling for baseline levels of the outcome measure) indicated that the interview led to significantly greater sexual satisfaction and less discomfort with sexual self-disclosure at 5-week follow-up, compared to controls; the two conditions did not differ on follow-up sexual self-schema, sexual self-esteem, or psychological symptoms. Moderation analyses revealed that participation in the interview differentially improved the sexual self-schema of women with no past sexual experience, compared to women with sexual experience. These experimental findings suggest the value, rather than the risk, of clinicians encouraging Arab American women to openly disclose and discuss their sexual experiences and attitudes in a confidential, empathic setting.

The Effects of a Pain Psychology and Neuroscience Self-Evaluation Internet Intervention: A Randomized Controlled Trial.

OBJECTIVES: Many patients' chronic musculoskeletal pain is strongly influenced by central nervous system processes such as sensitization or amplification. Education about pain neuroscience can change patients' beliefs but has less consistent effects on pain outcomes. Patients may have greater clinical benefits if the educational intervention is personalized, and they evaluate various psychosocial risk factors with respect to their pain. We developed and tested a brief, internet-based Pain Psychology and Neuroscience (PPN) self-evaluation intervention. MATERIALS AND METHODS: From a patient registry, 104 adults reporting chronic musculoskeletal pain were randomized to the PPN intervention or a matched, active, education control condition. At baseline and 1-month (primary endpoint) and 10-month follow-ups, participants reported pain severity (primary outcome) and multiple secondary outcomes. Primary analyses compared the 2 experimental conditions using analyses of covariances; post hoc exploratory analyses compared the effects of PPN in subgroups of patients who met criteria for fibromyalgia (FM; n=50) or who did not (n=54; primarily spinal pain). RESULTS: At 1-month follow-up, compared with the control condition, PPN led to significantly lower pain severity (ηp =0.05) and interference (ηp =0.04), greater brain (ηp =0.07) and psychological (ηp =0.07) attributions for pain, and greater readiness for pain self-management (ηp =0.08). Effects on distress, pain catastrophizing, kinesiophobia, and life satisfaction were not significant. Exploratory analyses showed that the PPN intervention was especially beneficial for patients without FM but was of less benefit for those with FM. Most of the effects (except attributions) were lost at 10 months. DISCUSSION: A brief PPN self-evaluation intervention, presented on-line, can yield short-term improvements in musculoskeletal pain severity and interference, especially for people with spinal/localized pain rather than FM, perhaps because the psychology/neuroscience perspective is more novel for such patients.

Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Functionalsomatic disorders (FSD) are common and costly, thereby driving the need for the development of effective brief treatment options. Short-term psychodynamic psychotherapy (STPP) is one candidate treatment method. OBJECTIVE: To review and meta-analyze, where possible, randomized controlled trials (RCTs) of STPP for FSD. METHODS: Following a systematic search of the literature, we performed a meta-analysis of available RCT groups to determine the effects of STPP on a range of outcomes after treatment, and medium- and long-term follow-ups. RESULTS: In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias. CONCLUSIONS: STPP is a valid treatment option for diverse FSD conditions resulting in somatic symptom reductions that persist over time. STPP should be included in FSD treatment guidelines.

Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial.

OBJECTIVE: Emotional awareness and expression therapy (EAET) emphasizes the importance of the central nervous system and emotional processing in the etiology and treatment of chronic pain. Prior trials suggest EAET can substantially reduce pain; however, only one has compared EAET with an established alternative, demonstrating some small advantages over cognitive behavioral therapy (CBT) for fibromyalgia. The current trial compared EAET with CBT in older, predominately male, ethnically diverse veterans with chronic musculoskeletal pain. DESIGN: Randomized comparison trial. SETTING: Outpatient clinics at the West Los Angeles VA Medical Center. SUBJECTS: Fifty-three veterans (mean age = 73.5 years, 92.4% male) with chronic musculoskeletal pain. METHODS: Patients were randomized to EAET or CBT, each delivered as one 90-minute individual session and eight 90-minute group sessions. Pain severity (primary outcome), pain interference, anxiety, and other secondary outcomes were assessed at baseline, post-treatment, and three-month follow-up. RESULTS: EAET produced significantly lower pain severity than CBT at post-treatment and follow-up; differences were large (partial η2 = 0.129 and 0.157, respectively). At post-treatment, 41.7% of EAET patients had >30% pain reduction, one-third had >50%, and 12.5% had >70%. Only one CBT patient achieved at least 30% pain reduction. Secondary outcomes demonstrated small to medium effect size advantages of EAET over CBT, although only post-treatment anxiety reached statistical significance. CONCLUSIONS: This trial, although preliminary, supports prior research suggesting that EAET may be a treatment of choice for many patients with chronic musculoskeletal pain. Psychotherapy may achieve substantial pain reduction if pain neuroscience principles are emphasized and avoided emotions are processed.

Pressure Pain Tolerance Predicts the Success of Emotional Awareness and Expression Therapy in Patients With Fibromyalgia.

OBJECTIVES: Quantitative sensory testing may help predict treatment responses in individuals with chronic pain. Our objective was to determine whether evoked pain sensitivity at baseline predicted preferential treatment responses to either emotional awareness and expression therapy (EAET) or cognitive behavioral therapy (CBT) in individuals with fibromyalgia (FM). METHODS: This was a secondary analysis of a previous randomized clinical trial, in which individuals with FM were randomized to EAET, CBT, or Education as a control intervention. Only females who completed baseline and post-treatment assessments were analyzed (n=196). The primary outcome was change in overall clinical pain severity from pretreatment to posttreatment, and the primary predictor of interest was pressure pain tolerance at baseline. RESULTS: Among patients with low pain tolerance at baseline (n=154), both EAET and CBT led to small but significant improvements in clinical pain severity (CBT mean=0.66, 95% confidence interval [0.24-1.07]; EAET mean=0.76 [0.34-1.17]). Conversely, in patients with normal pain tolerance (n=42), there was no significant improvement in clinical pain after CBT (0.13 [-0.88 to 1.14]), a small improvement after FM Education (0.81 [0.14-1.48]), but a much larger and statistically significant improvement after EAET (2.14 [1.23-3.04]). DISCUSSION: Normal levels of pressure pain tolerance at baseline predicted greater improvement in clinical pain severity after EAET than CBT. Quantitative sensory testing may provide insights about individual responses to psychologically based therapies for individuals with chronic pain.

Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review.

PURPOSE OF REVIEW: Patients with chronic pain, especially primary or centralized pain, have elevated rates of psychosocial trauma and intrapersonal or intrapsychic conflict. To address these risk factors and potentially reduce pain, the authors developed emotional awareness and expression therapy (EAET). This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base. RECENT FINDINGS: Four initial trials (between 2006 and 2011) demonstrated the efficacy of earlier versions of EAET. Four recent randomized, controlled trials of different EAET durations (1 to 8 sessions) and formats (individual or group) in patients with fibromyalgia, irritable bowel syndrome, pelvic pain, or medically unexplained symptoms support the earlier findings. EAET reliably reduces pain and interference, although improvements in anxiety and depression are less reliably achieved and may be delayed. The largest and best conducted trial found superiority of EAET over cognitive-behavioral therapy for fibromyalgia. Patient retention in EAET is high, and adverse events are rare. EAET merits inclusion as a treatment option for primary pain conditions, and it may be the preferred treatment for some patients. Research is needed on EAET with other pain conditions and samples, using better controls and comparison conditions, and on additional ways to motivate and help patients engage in successful emotional processing.

Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model.

OBJECTIVE: Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed. METHODS: We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance/mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges. RESULTS: Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress. CONCLUSIONS: This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.