Cognitive Behavioral Therapy for Chronic Pelvic Pain: What Is It and Does It Work?

PURPOSE: Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome in women and men and chronic prostatitis/chronic pelvic pain syndrome in men, is a common, often disabling urological disorder that is neither well understood nor satisfactorily treated with medical treatments. The past 25 years have seen the development and validation of a number of behavioral pain treatments, of which cognitive behavioral therapy (CBT) is arguably the most effective. CBT combines strategies of behavior therapy, which teaches patients more effective ways of behaving, and cognitive therapy, which focuses on correcting faulty thinking patterns. As a skills-based treatment, CBT emphasizes "unlearning" maladaptive behaviors and thoughts, and replacing them with more adaptive ones that support symptom self-management. MATERIALS AND METHODS: This review describes the rationale, technical procedures, and empirical basis of CBT. RESULTS: While evidence supports CBT for treatment-refractory chronic pain disorders, there is limited understanding of why or how CBT might work, for whom it is most beneficial, or the specific UCPPS symptoms (eg, pain, urinary symptoms) it effectively targets. This is the focus of EPPIC (Easing Pelvic Pain Interventions Clinical Research Program), a landmark NIH trial examining the efficacy of low-intensity, home-based CBT for UCPPS relative to a nonspecific comparator featuring self-care recommendations of AUA guidelines. CONCLUSIONS: Systematic efforts to increase both the efficiency of CBT and the way it is delivered (eg, home-based treatments) are critical to scaling up CBT, optimizing its therapeutic potential, and reducing the public health burden of UCPPS.

Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS).

BACKGROUND: Urologic chronic pelvic pain syndrome (UCPPS) encompasses several common, costly, diagnoses including interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome that are poorly understood and inadequately treated with conventional medical therapies. Behavioral strategies, recommended as a first-line treatment for managing symptoms, are largely inaccessible, time and labor intensive, and technically complex. The Easing Pelvic Pain Interventions Clinical Research Program (EPPIC) is a clinical trial examining the efficacy of low-intensity cognitive behavioral therapy (Minimal Contact CBT or MC-CBT) for UCPPS and its durability 3 and 6 months post treatment. Additional aims include characterizing the operative processes (e.g., cognitive distancing, context sensitivity, coping flexibility, repetitive negative thought) that drive MC-CBT-induced symptom relief and pre-treatment patient variables that moderate differential response. METHODS: UCPPS patients (240) ages 18-70 years, any gender, ethnicity, and race, will be randomized to 4-session MC-CBT or a credible, non-specific education comparator (EDU) that controls for the generic effects from simply going to treatment. Efficacy assessments will be administered at pre-treatment, 2 weeks, and 3 and 6 months post treatment-week acute phase. A novel statistical approach applied to micro-analytic mediator assessment schedule will permit the specification of the most effective CBT component(s) that drive symptom relief. DISCUSSION: Empirical validation of a low-intensity self-management therapy transdiagnostic in scope has the potential to improve the health of chronic pelvic pain patients refractory to medical therapies, reduce social and economic costs, conserve health care resources, as well as inform evidence-based practice guidelines. Identification of change mechanisms and moderators of treatment effects can provide proactive patient-treatment matching fundamental to goals of personalized medicine. TRIAL REGISTRATION: Clinicaltrials.gov NCT05127616. Registered on 9/19/21.

Cognitive flexibility improves in cognitive behavioral therapy for irritable bowel syndrome but not nonspecific education/support.

This study tested the novel hypothesis that CBT-treated IBS patients who learn to self-manage painful GI symptoms by targeting rigid cognitive style show improvement in cognitive flexibility, GI symptoms (e.g., abdominal pain), and quality of life. Participants included 130 Rome-III diagnosed IBS patients (M age = 40.3, F = 83%) with moderate-to-severe symptoms randomly assigned to either cognitive behavioral therapy (CBT; N = 86) or a nonspecific education/support (EDU) comparator (N = 44). Participants completed an assessment battery at baseline and post-treatment 2 weeks after 10-week acute treatment phase. Measures included cognitive flexibility, psychological flexibility, emotion regulation strategies, IBS symptom severity, quality of life (QOL), and distress. CBT but not EDU patients showed significant GI sympton improvement from baseline to post-treatment in cognitive flexibility. For CBT patients, changes in cognitive flexibility were significantly associated with changes in IBS symptom severity, abdominal pain, and IBS QOL. Neither condition showed significant changes in psychological flexibility (Acceptance and Action Questionnaire-II) or use of emotion regulation strategies (Emotion Regulation Questionnaire). The ability to self-manage painful IBS symptoms refractory to conventional medical and dietary treatments is related to the ability to respond flexibly across shifting contexts using cognitive change procedures featured in CBT for IBS.

Do I really have to do my homework? The role of homework compliance in cognitive behavioral therapy for irritable bowel syndrome.

Treatment guidelines identify cognitive behavioral therapy (CBT) as a treatment of choice for irritable bowel syndrome (IBS). As a learning-based treatment, homework assignments are regarded as important for optimizing outcomes for CBT-treated patients. However, their actual benefit for IBS is unknown. This study examined whether homework completion corresponds with immediate and sustained treatment response in IBS patients enrolled in CBT treatment. Subjects were 358 IBS patients receiving clinic-based CBT (10 session), home-based CBT (4 session), or a 4 session, non-specific IBS education comparator as part of a large NIH trial. Homework completion was rated by clinician at each session. IBS symptom improvement was measured with the Clinician Global Improvement Scale at treatment week 5, post-treatment (week 12), and at follow-ups (weeks 22, 34, 46, 62). Homework completion rates over the 10-week acute phase corresponded with greater IBS symptom improvement and patient satisfaction at post-treatment. Early treatment homework completion did not predict early treatment response. Contrary to expectations, homework compliance rates were not greater among in-clinic session patients than home-based patients. Data lend empirical support to the clinical value of homework in teaching patients how to self-manage painful GI symptoms refractory to conventional medical and dietary therapies.

IBS Patients' Treatment Expectancy and Motivation Impacts Quality of the Therapeutic Alliance With Provider: Results of the IBS Outcome Study.

BACKGROUND: In the absence of a satisfactory medical or dietary treatment, the quality of the therapeutic alliance between irritable bowel syndrome (IBS) patients and their provider is deemed critical to managing refractory IBS. Surprisingly, little research has been conducted on the nature of the therapeutic alliance, factors that influence it, or practical strategies to improve it. This study sought to identify actionable variables that impact therapeutic alliance in patients with refractory IBS. METHODS: Subjects included a total of 436 Rome III-diagnosed IBS patients (80% female, mean age=41.39 y) who completed a battery of clinical measures at the beginning of the acute treatment phase of an National Institutes of Health (NIH) behavioral trial. Pretreatment candidate predictor variables were organized into 4 categories: sociodemographic, extraintestinal, interpersonal, clinical (eg, symptom severity, pain intensity), cognitive (eg, treatment motivation, expectancy for improvement). Alliance was assessed by patient and clinician-rated measures of the Working Alliance Inventory after first treatment session. RESULTS: Patient reports of alliance were most strongly and consistently predicted by patient access to interpersonal support [ß=0.16; 95% confidence interval (CI)=0.07-0.25], motivation for IBS symptom improvement (ß=0.12; 95% CI=0.02-0.21), and expectancy of IBS symptom improvement (ß=0.35; 95% CI=0.25-0.44). Therapist ratings of alliance also were predicted by patient expectancy of IBS symptom improvement (ß=0.16; 95% CI=0.05-0.26). CONCLUSION: When managing IBS, a focus on dynamic factors of treatment motivation, social support, and treatment expectancy may be useful in improving the quality of the therapeutic alliance between patient and clinical gastroenterologist.

Pain Experiences and Their Relation to Opioid Misuse Risk and Emotion Dysregulation.

Pain is a complex, multidimensional experience but often is measured as a unidimensional experience. This study aimed to separately assess the sensory and affective components of pain and identify their relations to important pain-related outcomes, particularly in terms of opioid misuse risk and emotion dysregulation among patients with chronic pain receiving treatment in Appalachia. Two hundred and twelve patients presenting to a multidisciplinary pain center completed the Difficulties in Emotion Regulation Scale (DERS-18), Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), and short-form McGill Pain Questionnaire (SF-MPQ). The sensory experience of pain was unrelated to emotion dysregulation (r = 0.06, p = 0.57) and weakly related to opioid misuse risk (r = 0.182, p < 0.05). In contrast, the affective experience of pain was moderately related to emotion dysregulation (r = 0.217, p < 0.05) and strongly related to opioid misuse risk (r = 0.37, p < 0.01). In addition, emotion dysregulation predicted variance in opioid misuse risk above and beyond the affective and sensory experiences of pain ((b = 0.693, p < 0.001). The results suggest patients with a strong affective experience versus sensory experience of pain and challenges with emotion regulation may require a more comprehensive intervention to address these underlying components in order to reduce their risk of misusing opioid medications.

Difficult Conversations: Training Medical Students to Assess, Educate, and Treat the Patient with Chronic Pain.

OBJECTIVE: Chronic pain, along with opioid abuse and misuse, continues to be a prevalent problem across the USA. Medical students have minimal training in biopsychosocial treatment of chronic pain and often lack the knowledge and skill necessary to address chronic pain with their patients. While there are a variety of treatment options available, research repeatedly has demonstrated that biopsychosocial treatment is the most effective option for chronic pain. Engaging patients in this type of treatment requires training and education. METHODS: The authors implemented a simulation workshop with standardized patients to educate medical students on the physical, psychological, and social aspects of chronic pain and also train students on the most effective ways to discuss chronic pain and educate their patients. Outcomes were measured by a pre- and post-test survey of knowledge, attitudes, and confidence in treating chronic pain, as well as satisfaction with the learning experience. RESULTS: Test and survey results indicated improvements in knowledge, attitudes, and confidence in treating chronic pain. Additionally, students were satisfied with the experience as evidenced by high post-workshop ratings. CONCLUSIONS: Chronic pain training during medical school is associated with students feeling more prepared to provide non-opioid biopsychosocial pain treatment. Additionally, training with standardized patients allows students to learn how to effectively educate their patients, reduce negative confrontations, and maintain a positive physician-patient relationship.

Chronic Pain Rehabilitation for Upper Extremity Pain Following Stimulator Removal.

BACKGROUND Both spinal cord stimulators (SCS) and interdisciplinary chronic pain rehabilitation program (CPRP) are evidence-based treatments for chronic pain but differ on treatment foci. SCS focuses on decreasing the subjective pain experience as a means of improving function and quality of life. CPRP focuses on addressing the cognitive, emotional, and behavioral factors associated with chronic pain to improve function. Due to experimental constraints, these 2 treatment options are difficult to compare; however, this case report offers a unique opportunity to examine outcomes for both interventions in a sequential manner for changes in pain, function, and mood. CASE REPORT This single case study examined the separate and sequential outcomes of SCS and CPRP in a 26-year-old patient with a work-related injury resulting in chronic upper extremity pain. This patient was treated within an interdisciplinary CPRP following failure and removal of an SCS. Outcomes were measured by psychological assessments and return-to-work through a 6-month post-CPRP follow-up. CONCLUSIONS Pain intensity decreased following SCS placement and CPRP, while pain-related distress, pain interference, and overall affect improved only after CPRP, with sustained improvements at 6-month follow-up. Patient evidenced improvement following treatment with SCS and CPRP. SCS resulted in improvement in subjective pain and modest improved self-reported activity. CPRP demonstrated marked improvement in pain, self-reported function, and mood with patient eventually returning to work and maintaining most of these gains 6-months after completing CPRP treatment.

Difficulties in emotion regulation and chronic pain-related disability and opioid misuse.

Risk for opioid misuse is a crucial consideration for patients with chronic pain, given the recent high rates of opioid-related deaths in the U.S. Emotion regulation difficulties may be associated with chronic pain outcomes such as opioid misuse, but may also be amenable to intervention. The aim of this study was to examine associations between difficulties with emotion regulation and disability and risk for opioid misuse among Appalachian chronic pain patients. The Difficulties in Emotion Regulation scale (DERS-18), Pain Disability Index (PDI), Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP-R), and Current Opioid Misuse Measure (COMM) were collected from 149 patients (age 25-80, 59% female) presenting to a behavioral medicine department for evaluation. The extent to which DERS-18 scores predict risk for opioid misuse and disability was examined via hierarchical regression, logistic regression, and receiver operating characteristic (ROC) curve analyses. DERS-18 scores account for 45% of variance in SOAPP-R, 36% in COMM scores, and 11% in PDI scores. A one-point increase in DERS-18 score is associated with 19% greater odds of being at risk for misuse as measured by the SOAPP-R, and 16% greater odds on the COMM. In ROC analyses, the DERS-18 is a good predictor of risk on the SOAPP-R (AUC = .85) and COMM (.83), with cut-off scores in the mid-30s exhibiting good sensitivity and specificity. Difficulties in emotion regulation are associated with poorer functioning and with greater risk of opioid misuse in this population, but may be amenable to intervention.

Impact of a Psychological Opioid-Risk Evaluation on Opioid Prescribing in Primary Care.

BACKGROUND AND OBJECTIVES: The misuse and abuse of opioids has increased across the United States in recent years, associated with a rise in opioid-related overdose deaths. Physicians report having difficulty discerning substance abuse or drug diversion, which can lead to over- or under-prescribing of opioids and poor pain management. Additionally, research suggests that patient characteristics (eg, sex, ethnicity/race, age) may unduly influence the pain management decisions of health care providers. This investigation aimed to assist in physicians' prescribing decisions and reduce prescribing bias through the assistance of mental health professionals. METHODS: This study utilized 151 chronic pain patients being considered for chronic opioid therapy to determine if a psychological opioid-risk evaluation influenced physicians' opioid prescribing. The evaluation resulted in an opioid-risk level (ie, low, moderate, high) being assigned to each patient representing their potential risk for misusing or abusing opioid medication. A record review was conducted on each patient, abstracting information about opioid prescribing, and several other factors, which were included in logistic regression analyses. RESULTS: Risk status and substance abuse history significantly predicted opioid prescribing, with a lower risk status associated with greater likelihood of opioid prescribing and those with a history of substance abuse being less likely to be prescribed an opioid; however, substance abuse did not significantly improve the overall model and was removed. Demographic variables were not significant predictors of prescribing contrary to findings in other studies. CONCLUSIONS: These findings suggest that providing physicians with additional information about their patients' opioid abuse potential aids in prescribing decisions and may reduce prescribing bias based on demographic factors.

The influence of health care professional characteristics on pain management decisions.

OBJECTIVE: Evidence suggests that patient characteristics such as sex, race, and age influence the pain management decisions of health care providers. Although this signifies that patient demographics may be important determinants of health care decisions, pain-related care also may be impacted by the personal characteristics of the health care practitioner. However, the extent to which health care provider characteristics affect pain management decisions is unclear, underscoring the need for further research in this area. METHODS: A total of 154 health care providers (77 physicians, 77 dentists) viewed video vignettes of virtual human (VH) patients varying in sex, race, and age. Practitioners provided computerized ratings of VH patients' pain intensity and unpleasantness, and also reported their willingness to prescribe non-opioid and opioid analgesics for each patient. Practitioner sex, race, age, and duration of professional experience were included as predictors to determine their impact on pain management decisions. RESULTS: When assessing and treating pain, practitioner sex, race, age, and duration of experience were all significantly associated with pain management decisions. Further, the role of these characteristics differed across VH patient sex, race, and age. CONCLUSIONS: These findings suggest that pain assessment and treatment decisions may be impacted by the health care providers' demographic characteristics, effects which may contribute to pain management disparities. Future research is warranted to determine whether findings replicate in other health care disciplines and medical conditions, and identify other practitioner characteristics (e.g., culture) that may affect pain management decisions.