Cognitive Behavioral Treatment

摘要

This chapter addresses the place of cognitive behavioral treatment (CBT) for chronic pain, and examines the most important sources of variance in outcome of CBT. Consideration of how CBT can become more effective leads to a "normal psychology of pain" and reflection on the next generation of treatment and treatment studies. CBT is still largely delivered only after all other interventions have failed, to those whose pain problem persists despite addressing its cause where identified, and after various medical and physical analgesic interventions. Is this its only and proper place, or might psychological problems be addressed alongside treatment of the cause of pain and of pain itself? We know that psychological problems are not simply the consequence of persistent pain. Distress measured during acute pain predicts the likelihood of persistent pain and disability, as well as long-term distress, far more accurately than do biological measures, pain intensity, or extent of disability during the acute stage. Those data come from an important systematic review of prospective studies of low back pain in primary care by Pincus et al. (2002). Distress in these studies is largely measured by catastrophizing, but is likely also to comprise fear of persistent pain and bodily harm, which will doubtless be studied further in the next 10 years. Fear is clearly associated with disability because it generates avoidanee (of feared activities and physical demands), and avoidance constitutes functional shortcomings that cannot be attributed directly to physical impairment or pain. The literature on pain and fear is best summarized in a state of the art review by Vlaeyen and Linton (2000), and is discussed by Vlaeyen in this volume.