Cognitive Behavioral Therapy

by Nicole Berardoni M.D., Paul Lynch M.D., and Tory McJunkin M.D.

Cognitive Behavioral TherapyCognitive behavioral therapy is a common psychosocial therapy used in the treatment of many different chronic pain states. CBT theorizes that a maladaptive thought process can cause negative behaviors and emotions. In multiple studies, negative emotions have been shown to increase average pain scores. The goal of CBT is to make you aware of negative thoughts and emotions so that you can consciously change them. Healthy positive thoughts and emotions replace the negative ones, causing a powerful impact on your life and decreasing your pain. Many different disorders are treated successfully by CBT, including mood disorders, anxiety disorders, and chronic pain. The specific CBT methods used varies with each type of disorder, so it is important for the CBT therapist to be familiar with the patient and goals of therapy.

Some of the commonly tools used in CBT are:

  • Journal writing – Patients are asked to keep a daily journal of the day’s events and associated feeling, emotions, and actions. They are asked to record the most stressful parts of their day and their associated pain scores.
  • Conditioning – The CBT therapist uses positive or negative reinforcement to encourage helpful behaviors.
  • Systematic desensitization – This is frequently used in patients with anxiety disorders. Patients imagine an uncomfortable or fearful situation, and the CBT therapist helps the patient to relax through it. Gradually the patient becomes desensitized to the fear-producing stimuli and instead associates relaxation with the stimuli.
  • Cognitive rehearsal – The patient imagines a problematic circumstance, and the therapist helps them through the process. Fears and negative emotions are identified, and the circumstance is thought about with a healthy frame of mind.

Cognitive Behavioral Therapy in Chronic Pain

Cancer-PainCognitive behavioral therapy is frequently used as a technique to cope with pain that is chronic for patients with illnesses such as rheumatoid arthritis, fibromyalgia, back pain, and cancer. CBT focuses on factors that exacerbate or prolong chronic pain and should be considered as part of a multidisciplinary treatment paradigm (Molton 2007). Patients who suffer from chronic pain commonly develop co-existing depression. Many recent studies focus on a patient’s state of mind and the ability to control their pain level. Many of these studies show an improved quality of life and overall reduction in average pain scores.

Cognitive Behavioral Therapy in Depression

Cognitive behavioral therapy has shown to be as useful as antidepressant medication for individuals with depression. In a large research study, there were substantially higher results of response and remission from depression when a form of cognitive behavior therapy was used in addition to antidepressant drugs than when either method was used alone (Keller 2000). With CBT, patients suffering from depression learn how to rearrange negative thought patterns in order to influence their daily life activities. CBT for depression involves changing two main contributing factors to depression: negative emotions and social withdrawal (tendency to stop enjoyable activities). Patients suffering from depression typically have a downward spiral. The onset of depression comes on slowly with negative feelings present. Then, the person tends to stop doing pleasurable activities. Finally, depression sufferers can become unable to function in their daily life. Changing negative thought associations with depression along with helping patients to participate in gratifying activities are the goals of CBT. When these goals are accomplished, they have proven to be extremely successful in treating depression.

Cognitive Behavioral Therapy in Anxiety

CBT is also a useful treatment for anxiety disorders, including phobias, panic attacks, and obsessive-compulsive behaviors. In CBT, patients learn to be aware of and change maladaptive thinking patterns. CBT is not just “thinking happy thoughts and all of your problems go away”; it is a way to gain conscious control over unwanted thoughts or feelings which are typically associated with anxiety. Patients who have certain phobias benefit from a CBT method that uses exposure to what they fear and gradual improvement of their reactions to the object or situation. Those who suffer from panic attacks are made aware of their body’s negative responses and actions during these attacks. During CBT they develop methods to counteract the reason for their panic attacks. Additionally, people who have obsessive-compulsive tendencies are encouraged to expose themselves to what they fear and identify what they truly fear.

Other Uses for Cognitive Behavioral Therapy

Family StressCognitive behavioral therapy has been used in numerous disorders including mental disorders, personality disorders, phobias, eating disorders, substance abuse, post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD). Patients with sleep disorders may also find cognitive-behavioral therapy a useful treatment for insomnia. CBT for insomnia can improve sleep quality, reduce hypnotic drug use, and improve quality of life in patients with chronic sleep difficulties (Morgan 2004).


Many patients who undergo cognitive behavioral therapy successfully learn how to replace their negative or unwanted thoughts and behaviors with healthier, more positive ones. Oftentimes these changes can improve quality of life and decrease pain for chronic sufferers. CBT is especially useful in conjunction with other therapies and modalities to relieve chronic pain.

Journal Articles

  1. Keller, M. et al. A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression. New England Journal of Medicine Volume 342:1462-1470 May 18, 2000
  2. Psychological treatment for insomnia in the regulation of long-term hypnotic drug Morgan K, Dixon S, Mathers N, Thompson J, Tomeny M. Health Technol Assess. 2004 Feb;8(8):iii-iv, 1- PMID: 14960254
  3. Current psychological approaches to the management of chronic pain Molton IR, Graham C, Stoelb BL, Jensen MP. Curr Opin Anaesthesiol. 2007 Oct;20(5):485 PMID: 17873602