Paris—Treatment of chronic pain can be challenging, partly because of the associated problems of depression and anxiety. The patient–provider relationship is one of the key components of managing the psychological aspects of chronic pain, according to experts addressing attendees at the recent 2014 annual meeting of the European League Against Rheumatism.

“Chronic pain is very tricky to treat. For a number of patients, their pain is essentially permanent and ‘untreatable,’ in the sense that it is not going to fully go away. Thus, the treatment can focus on helping patients to be as functional as possible with chronic pain,” said Kevin E. Vowles, PhD, associate professor in the Department of Psychology, the University of New Mexico, Albuquerque, who spoke at the meeting.
The way in which physicians conduct themselves can influence outcomes, he said. Trust is essential, and the physician needs to convey that he or she has the patient’s best interest in mind.
Trust is particularly critical to adherence, said Dr. Vowles, adding that “we know that just telling patients what to do does not work very well.” The physician needs to encourage behavioral change so that patients can adapt their expectations and become comfortable with their experience of pain, he said. For some individuals with chronic pain, this seems to be a viable option, particularly when treatments aimed primarily at pain control have failed to provide benefit or are disrupting functioning.
“Psychology is all about behavior change, which is why it is important in the rehabilitation of chronic pain,” he said. “The ultimate outcome of treatment is not to alter an internal perception but to change the way patients respond to their pain so that they can get on with their lives, ideally in a manner that also allows increased engagement in valued and meaningful activity.”
It is not useful for the patient to try to determine if the pain is “real” or “psychogenic,” he said. ”This dichotomy does not help patients or providers. This is really an outdated concept. For example, in his 1976 book [“Behavioral Methods for Chronic Pain and Illness”], Wilbert E. Fordyce, PhD, outlined many ideas of psychogenic pain that were inaccurate at that time.”

The provider needs to help patients understand that their pain experience will affect their emotions and behavior, and the provider should find ways to help the patient accept the pain and behave so that the pain has as minimal an impact on function as possible.
Some psychological strategies for the treatment of chronic pain include use of acceptance and commitment therapy (ACT), and mindfulness approaches as part of cognitive-behavioral therapy (CBT). These therapies can help patients view their pain in context and make behavioral changes that accommodate the pain, Dr. Vowles said.
“I think treating the psychological components of chronic pain is absolutely critical,” agreed Ellen Slawsby, PhD, director of pain services at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital in Boston.
Patients with chronic pain have high rates of anxiety and depression, she said. “We have found that 75% have depression, 60% have reduced enjoyment of life, 70% have poor concentration and 75% have sleep disturbances.
“We know pain is exacerbated by the flight-and-fight response [i.e., anxiety]. Paying attention to patients’ psychology will improve symptom control and quality of life,” she said.
Mind–body approaches are important, she noted. “Both ACT and CBT are part of mind–body approaches. Data show that the true relaxation response helps patients with chronic pain get better.”
—Alice Goodman