Ascellus Blog

How and Why CBT Relieves Chronic Pain – Part II

January 18, 2018


Chronic pain often breeds a variety of comorbidities; depression, anxiety and insomnia among the main ones. The research is not clear in terms of whether the pain causes or exacerbates these conditions or vice versa. What we do know is that we can greatly help injured workers reduce these and other symptoms — along with the pain itself.

● Do you see injured workers with chronic pain being treated for a variety of comorbidities?
● What interventions are being used?
● How effective have these interventions been?

Cognitive behavioral therapy (CBT) has been shown to be a valuable intervention to treat disorders associated with chronic pain. This brief, goal-based strategy also improves compliance with treatment with many aspects of physical issues, such as smoking cessation, physical therapy, time spent conditioning and a better diet.

Chronic Pain Comorbidities
Injured workers with chronic pain have thoughts and emotions that are essentially working against them. CBT can lead to improved symptom management because thoughts are deeply connected with automatic, unconscious survival needs and, therefore, preventions and defense behaviors.

We explain CBT to injured workers by first pointing out that chronic pain is due to cognitive distortions, and the thoughts and emotional states which derive from them mediate the perception of pain. Cognitive distortions decrease individuals’ functioning by influencing the way they represent their own lives and how they act and behave daily.

With chronic pain patients, cognitive distortions are frequently associated with anger and rage paired with injury beliefs, creating hyperarousal and increasing perceived pain. Angry beliefs are strongly related to cognitive distortions, especially when considering that the person with whom the injured worker is most angry is himself.

Anger, when not openly expressed, can lead to secondary problems, such as external locus of control. Injured workers with external locus of control blame others for their plight, whereas those with an internal locus of control perceive pain less intensely and are able to cope more effectively.

Combining CBT, with other strategies, such as physical exercise, medications, and relaxation training helps patients switch control from external to internal, helping them manage their pain better.

CBT Application

Sleep — Poor sleep quality is common in chronic pain patients In fact, many studies show that 50- to 90-percent of chronic pain patients report clinically poor sleep conditions. This is particularly true for older adults, who report difficulties in falling asleep, staying asleep and sleeping longer than usual when they experience chronic pain conditions.

As with other comorbidities associated with chronic pain, it is still not clear if pain aggravates insomnia or if insomnia intensifies pain.

Sleep problems lead to other secondary conditions, such as physical inactivity and persistent fatigue, which in turn intensify the pain experience and lead to greater disability. Moreover, better sleep quality leads to reduced depression and fatigue. It also has been linked to less attention focused on symptoms, lower pain intensity and higher physical activity.

There is a specific CBT approach for insomnia that can be paired with medical treatments and other medical interventions. Hypnosis, for example, has been shown to positively affect the ability to fall asleep, return to sleep if awakened, and to feel rested in the morning.

Interventions that are often paired with CBT include:

● Sleep hygiene. These are strategies that improve the chances of falling asleep; such as avoiding caffeine in the afternoon, eliminating clocks from the bedroom, and going to bed to sleep only when tired.
● Sleep restriction therapy. This intervention forces the patient sleep time into a fixed window, which is shorter than the patient’s habits.
● Sleep scheduling. The goal of this is to strengthen the sleep-bed connection by avoiding engagement in other activities, such as reading, and to restrict the time spent in bed.
● Relaxation.
● Imagery.

Depression and catastrophizing
More than half of injured workers with chronic pain report clinical symptoms of depression. There could be a neurobiological origin, as the neurotransmitter serotonin and the naturally occurring chemical norepinephrine moderate both pain and mood. The research shows that depression and chronic pain can have a cyclical relationship; meaning increases in pain predict increases in depression and vice versa.

CBT has been shows to be as or more effective than medications to treat depression and the results last longer with CBT alone, or in combination with other interventions, such as biofeedback. CBT is also an effective first-line approach for chronic pain patients with anxiety.

There are also studies showing a significant association with catastrophizing, which is considered a severe anxiety symptom strongly related to cognitive distortions, as it is the exaggeration of the threat of pain, combined with the rumination about pain and perceived helplessness to cope with it. The higher the depression and catastrophizing symptoms, the higher the pain severity, sensitivity to pain, and physical disability treatment was also less effective.

We know that it’s critical to treat catastrophic thinking, since it leads to poorer pain adjustment. As catastrophic thinking decreases, the injured worker’s confidence in his ability to engage in everyday activities increases, which ultimately leads to reduced pain.

Hypnosis is effective in helping some chronic pain patients with depression and anxiety. Acceptance and Commitment Therapy (ACT) is another intervention that can help these injured workers. ACT incorporates acceptance strategies, mindfulness, and other behavioral approaches that focus on the injured worker’s relationship to his experiences, in terms of his thoughts, feelings, memories, and bodily reactions.

Injured workers with chronic pain typically suffer with a variety of conditions in addition to the pain itself. Focusing on only one symptom ignores the fact that there is quite a bit of interplay among the comorbidities. Interventions such as CBT help the injured worker understand and identify his symptoms and teach him to manage all of them.

We’d like to hear from you.

● Do you see injured workers with chronic pain being treated for a variety of comorbidities?
● What interventions are being used?
● How effective have these interventions been?

Please share your thoughts with us.

Integrated Medical Case Solutions (Ascellus) is a national network of Health Providers in Psychology that delivers cognitive behavioral therapy (CBT) for chronic pain, trauma and insomnia across the country for the workers’ compensation industry.

For additional information, contact us at, or Please join our LinkedIn group, COPE with Pain at  Read full article here:


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Ascellus bridges the gap between mental and physical health to accelerate recovery for our nation's workforce. By connecting the workers' compensation industry with our expert behavioral care and evidence-based treatments, we deliver high-quality outcomes, helping injured workers reemerge with increased strength, purpose and resilience in the workplace.