See Part 1.
2. ESSENTIALS OF ASSESSMENT
See Part 1.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Physical or biologic disorders that culminate in chronic pain, illness, and disability from loss of mobility, function, and/or independence are commonly encountered in virtually all subspecialties of physical medicine and rehabilitation practice. Many individuals afflicted with a devastating illness or injury endure an adjustment period as a reaction to the stressful life event; some may go through a grieving process from loss of the “old self”. Most recover over time and ultimately adjust positively to their disability and impairment(s) and lead meaningful and fulfilling lives. A significant number, however, remain chronically burdened by persistent psychological distress or psychiatric illness, amplified by their inability to cope with pain and/or disability.
In the rehabilitation patient population, chronic pain is a major source of suffering and a potential barrier to rehabilitation and adaptation. In chronic pain syndromes, when pain becomes more disabling than the underlying biologic injury, or when pain is the sole or primary complaint in the absence of significant biologic injury, chronic pain may be conceived as a disease in its own right.
As defined by the IASP (The International Association for the Study of Pain), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. While biologically serving an aversive and adaptive purpose that is vital to individual (and species) survival, pain can also develop and endure in the absence of apparent biologic injury or can exceed the degree of biologic injury (as in complex regional pain syndrome). Moreover, pain from biologic injury can persist beyond the period of expected tissue healing and, in such cases, may no longer serve a useful purpose. Pain can then become a destructive force. Pain is a complex perceptual phenomenon in addition to a sensory experience that can be influenced by neurobiological, psychological, socio-cultural factors, and learned cognitive and behavioral responses acquired through previous personal and observed traumatic experiences. Viewing pain from a perceptual, and not exclusively a biologic, narrative allows for a much greater recognition of the cognitive, affective, behavioral, and social components of the pain experience. Once concrete negative beliefs and expectations about pain are formed, they tend to drive maladaptive behaviors and thoughts which can become challenging to extinguish. Individuals who have little or no control over their pain are more likely to catastrophize about their pain and suffering and develop aversive behaviors to minimize or avoid exposure to activities and situations that trigger or amplify their pain.
“Psychological stress” and pervasive behavioral responses resulting from maladaptation to chronic pain, physical illness and/or injury, occurs when an individual perceives that physical, cognitive, emotional, social or environmental demands exceed his or her adaptive capacity. Depression, anxiety, post-traumatic stress disorder, and substance abuse disorders are common co-morbidities present in patients with chronic pain and physical disabilities.
Pain and nociception are not interchangeable terms. While pain is a unique and personal experience (subjective), nociception is defined by observable neurophysiologic activity in response to a noxious stimulus (objective). Psychological interventions for chronic pain primarily target improvements in physical, psychological, social, and occupational areas, rather than focusing on nociception itself.
Rehabilitation Psychology is an integral component of the multidisciplinary rehabilitation team. Rehabilitation psychologists receive additional specialty education, training and expertise in the management of psychologic needs of individuals typically managed in the rehabilitation setting.
Early recognition and treatment of significant psychologic distress that exceeds or extends beyond the expected duration of adjustment or grief is essential in patients with intrusive pain and/or disability. Early intervention can help individuals learn to adapt and cope, and potentially prevents maladaptation that can become pervasive over time.
Psychological therapeutic strategies are geared towards helping patients achieve a greater sense of control over their pain or disabilities by eliminating maladaptive physical and psychological responses and replacing them with positive coping mechanisms and constructive strategies.
Psychotherapies for pain should be deferred in individuals who have unstable mental health conditions (active psychosis or mania, active suicidality, active homicidality), until stability has been achieved. Concurrent treatment of pain and underlying psychiatric condition(s) can be achieved in individuals with untreated or under-treated psychiatric comorbidities including active substance abuse. Antidepressants can be selected to alleviate underlying depression and treat the underlying pain complaints as well. Similarly, cognitive behavioral approaches shown to be helpful in pain may also be effective for anxiety, depression, PTSD and substance use disorders. Aggressively addressing both the psychiatric illness and chronic pain is necessary for optimal recovery. Otherwise a vicious cycle can ensue wherein poorly treated pain may exacerbate the underlying psychiatric condition and, conversely, the untreated or under-treated psychiatric condition may exacerbate pain, disability and maladaptation 1.
Similar to other forms of therapies, psychological therapies are most successful when patients demonstrate interest, motivation, and compliance, and when a strong therapeutic alliance is developed between the patient and the provider.
Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning (improvements in pain-interference) rather than focusing on resolution of pain. However, psychological therapies vary in their scope, duration, and goals, and thus show distinct patterns of treatment efficacy 2. Individuals respond variably to specific psychological interventions and do not conform to a “one size fits all” treatment paradigm. It has yet to be determined which specific interaction is best suited for which individual 3. Psychotherapeutic treatments are ideally combined with anti-nociceptive therapies and physical rehabilitation as part of an integrated, interdisciplinary, multidimensional paradigm. It is critical to develop a multimodal biopsychosocial treatment approach that is tailored to the individual patient.
Available or current treatment guidelines
Most psychological interventions, including structured therapies, can be successfully conducted in individual or group settings. Telehealth and other internet-based patient-therapist interventions have also been employed with success.
COGNITIVE BEHAVIORAL THERAPY (CBT):
CBT is the most widely employed and thoroughly researched psychotherapeutic approach that has evidence-based efficacy for a number of mental and behavioral disorders, including many chronic pain conditions, depression, anxiety, and PTSD. CBT involves a structured, time-limited approach that focuses on the inextricable link between cognition (thoughts), emotions (feelings), and behaviors (actions) which complexly and variably interact to create maladaptation, catastrophizing, and global dysfunction 4.
CBT employs a “problem-focused” and “action-oriented” approach. The aim of cognitive behavioral therapy is to extinguish maladaptive thoughts, beliefs, and behaviors that lead to increased pain, emotional distress, withdrawal from activities, and social isolation. CBT aims to replace them with positive and rewarding alternatives, as well as foster acquisition of new coping skills and techniques. The individual is first taught to identify and record maladaptive thoughts, beliefs and behaviors that induce stress, anxiety, sadness, anger and increased pain, which are then systematically replaced with balanced and productive ones.
Other essential components of CBT include:
- Stress and anger management
- Relaxation strategies
- Identification and modification of adverse emotional and thought responses to perceived or real antagonistic behaviors of family, friends and other contacts that perpetuate maladaptive behaviors.
Treatment includes assertiveness training and improvement in communication skills. Distraction techniques are also employed as they can be an effective tool for exerting control over pain. CBT may also involve maintaining a pain diary.
CBT is generally conducted in a 3-step skill-building progression with each phase representing attainment of a higher level of skill development, understanding, application, functioning, motivation, and resiliency.
- Psychoeducational phase: During this patient education phase, concepts like the mind-body connection and pain-stress cycle, and their inextricable relationship to perpetuation of pain and suffering, are introduced to the individual. The patient is then encouraged and assisted in identifying and understanding the thoughts, beliefs, behaviors and attitudes that amplify pain, stress, anger, disability, and feelings of hopelessness, helplessness and despair, as well as those that mitigate or extinguish these aberrant thoughts and emotions, and, consequently, the behaviors that accompany them.
- Skills-building phase: assists the individual in developing cognitive and behavioral strategies to identify aberrant thoughts, emotions and behaviors and to counteract them with positive and rewarding coping alternatives that will help regain self-control and self-adaptation. Part of this phase is also devoted to the acquisition of other supportive coping strategies, such as stress management, anger management, assertiveness training, relaxation training, and pacing. Other psychotherapeutic tools such as meditation, relaxation techniques, self-hypnosis, biofeedback, as well as Yoga and Tai-Chi have also been introduced during this phase of CBT with favorable outcomes.
- Application Phase: The final step in CBT involves the individual applying the techniques and skills developed during the first two phases to create an enduring maintenance program. After successfully implementing and maintaining their newly acquired skills, patients are encouraged to further explore, modify, improvise, and expand their cognitive, behavioral, relaxation, and coping strategies in progressively more challenging domains in order to sustain persevering salutary changes in lifestyle and adaptation.
SELF-REGULATORY MIND-BODY (WHOLE-HEALTH) INTERVENTIONS OFTEN EMPLOYED WITH CBT:
Tai Chi, Qi Gong and Yoga: Other forms of mind-body interventions employed in pain management, include movement meditation adaptations of Tai Chi, Yoga and Qi Gong. These therapies combine meditation and movement to improve and maintain health. There are insufficient comprehensive studies at this time to assess the efficacy of these interventions in chronic pain.
Progressive Muscle Relaxation: Patients are instructed to simultaneously tense, then relax individual muscle groups in order to gain the ability to selectively relax stressed muscles.
Focused Breathing: Patients are taught to focus on breathing with actively controlled inspiration and expiration, which may help reduce stress, anxiety, sympathetic overactivity and pain and stress-related hyperventilation. Focused breathing is also an integral part of other mind-body therapies such as Tai Chi, Qi Gong and Yoga
Autogenic Relaxation: Patients receive instruction in focusing on systemic relaxation of specific body parts.
Guided Imagery: This technique can provide additional benefits after the individual has learned to achieve a relaxed state, by fostering an environment of calmness and pleasant feelings. Enhancement of coping skills can be achieved by employing imagery for desensitization by conjuring stressful situations while attempting to maintain a state of relaxation. Guided imagery can be employed as a stand-alone or adjunctive treatment.
Biofeedback: Biofeedback is a tool, not a specific treatment, employed to measure the progress and efficacy of other self-regulating mind-body therapies. It involves the gathering of real-time feedback of one or more physiological responses. Feedback modalities include skin temperature, muscle tension (surface electromyography), heart rate variability, electroencephalography, breathing, skin temperature and sudomotor responses.
MINDFULNESS-BASED COGNITIVE THERAPY (MBCT) AND MINDFULNESS BASED STRESS REDUCTION (MBSR):
Variations of self-regulated meditative techniques have been adapted as psychological approaches to treating pain as well as stress, anxiety and depression. Meditation approaches may be concentration-focused or mindfulness-focused. Concentrative meditation may be challenging in the presence of nagging pain which is constantly demanding the individual’s undivided attention.
Probably the best-known and most widely employed mindfulness meditative treatment for chronic pain is Mindfulness Based Stress Reduction (MBSR). Professor Jon Kabat-Zinn who developed the practice in the 1970s, defined mindfulness as “moment-to-moment non-judgmental awareness” of thoughts, emotions and sensations. Mindfulness-based cognitive therapy is a modified form of cognitive therapy that uses mindfulness strategies to extinguish negative thought patterns. It may also be helpful for treating generalized anxiety and substance use disorders, and improving symptoms of mood disorders.
Mindfulness-based interventions endeavor to decouple the sensory aspects of pain from the evaluative and emotional components and enable intrusion of somatic and cognitive sensations without becoming entangled by them 5. Through mindful awareness and meditation, distressful thoughts can be viewed as discrete events rather than sequelae of an underlying problem that demands immediate attention and cultivates aberrant responses. The individual is taught to recognize these thoughts as something familiar, which may help to ameliorate emotional or maladaptive behavioral responses 2.
Typically, MBSR interventions are structured as 2-hour sessions occurring weekly over 10 weeks. These sessions serve to develop awareness of the body, breathing, physical and intrapsychic sensations, and development of mindful counter-responses 5. MBSR promotes mindfulness primarily through daily meditation, which is a requisite component of the treatment. MBSR primarily serves to increase tolerance for negative emotions, thereby fostering more constructive and adaptive responses to pain 6. MBSR reduces rumination 7 and interoception of distressing physical signals 8, and increases mindful awareness 7 and pain acceptance. The mechanisms underlying effective MBSR intervention, similar to in vivo exposure therapy for pain, may induce desensitization to pain. Meditations involve motionless sitting practices that expose participants to painful sensations, in the absence of deleterious consequences 5,6.
Adherence rates of MBSR have been found to compare favorably to behavioral pain management techniques 9. Unlike CBT, which identifies thoughts as distorted and in need of change, mindfulness is geared towards a nonjudgmental approach to thoughts as “discrete events” that encourage emotional distance from thoughts 10,6. Since chronic pain signals are challenging to extinguish or ignore, this detachment may extinguish negative individual responses to chronic pain and foster positive alternatives 5.
MBSR has efficacy in reducing the severity of medical and psychological symptoms 5 and pain intensity 9,11. Additionally, MBSR addresses co-occurring symptoms of depression in individuals with some chronic pain conditions like fibromyalgia 12 and enhances the effects of multidisciplinary treatment on disability, anxiety, depression, and catastrophizing 13.
HYPNOSIS AND SELF-HYPNOSIS:
Hypnosis is an attention-focusing procedure in which changes in thoughts, emotions, behavior or perception are suggested directly or indirectly to the patient. Although it has historically been employed as a component of a multimodal treatment program, usually as an adjunct to CBT, there is growing empirically-supported evidence for its effectiveness as mainstream structured therapy for chronic pain, anxiety, depression and cognitive and behavioral disorders. Hypnotic analgesia has been shown to be equally effective in reducing both clinical and experimental acute pain associated with medical procedures.
The induction of hypnosis usually begins with suggestions for some form of relaxation, leading to sustained focus, followed by a specific suggestion to alter the individual’s view of the pain or stress experience, which, in turn, helps reduce acquired aberrant protective psychological defense mechanisms (self-judging, monitoring and avoidance).
Often, posthypnotic suggestions are added to extend the duration of benefits experienced during the treatment session to well beyond the hypnotic phase and/or provide post-hypnotic pain tolerance while subsequently engaging in specific pain or stress enhancing activities.
The enduring cost-effective goal of hypnosis is to train the individual in self-hypnosis techniques for long-term management of pain, discomfort, stress and avoidance behaviors beyond the structured hypnotic treatment sessions with the therapist.
ACCEPTANCE AND COMMITMENT THERAPY (ACT):
ACT adopts a theoretical approach which posits that thoughts do not need to be targeted to bring about change; rather responses to thoughts may be altered so that negative consequences are minimized 22. ACT interventions improve wellness through nonjudgmental and purposeful acknowledgment of thoughts and emotions, fostering acceptance of these events, and increasing the ability of the individual to remain present and aware of relevant psychological and environmental factors. By doing this, individuals are able to adjust their behavior in a way that is consistent with their goals or values, rather than focusing on immediate relief from pain and stress-induced thoughts and emotions 14.
In the treatment of pain, ACT fosters purposeful awareness and acceptance of pain, thereby minimizing the focus on reducing pain or thought content and instead directing efforts towards fulfilling behavioral functioning 10. ACT shares conceptual similarity with MBSR. Both promote mindfulness and acceptance of pain but, unlike MBSR, ACT does not utilize daily mindful meditation and instead focuses on identification of the values and goals of the individual, which serve to redirect behavior 15. ACT-based interventions have been shown to improve various aspects of mental health in chronic pain populations, including mental health, quality of life, self-efficacy, and mood 16. However, meta-analytic studies of acceptance-based therapies for pain have revealed that ACT does not show incrementally greater efficacy in comparison to other established psychological treatments for chronic pain 15.
ACT is most effective for mitigating pain-related anxiety and pain acceptance. It is less effective for mitigating pain intensity and pain interference.
OPERANT-BEHAVIORAL THERAPY (OBT):
Operant-Behavioral therapy is based on the premise that a learned behavioral drive to elude or minimize pain leads individuals to avoid situations that are painful, which only serves to amplify their physical and emotional ailments; this avoidance behavior contributes to the development and sustenance of pain chronicity, deconditioning, depression, and social withdrawal. Operant therapy for chronic pain utilizes reinforcement and punishment contingencies to reduce pain-related behaviors and foster more adaptive behaviors 17. Positive reinforcement increases the probability of the behavior being repeated while punishment aims to extinguish it. Negative reinforcement strengthens a response or behavior by preventing, removing, or avoiding a negative outcome or aversive stimulus. Behavioral therapy for pain has shown positive effects on pain experience, mood, negative cognitive appraisals, and functioning 17.
Learning theory postulates that aversive pain signals, which contribute to avoidant behavior, can be passed to neutral stimuli (like physical movement behaviors) 3.
In vivo exposure therapy aims to extinguish perceived threats, fear, and behavioral avoidance through progressively encouraging engagement in painful behaviors in the absence of catastrophic outcomes; when these behaviors are performed without serious negative consequences, patients may realize that their expectations about the consequences of physical movement and pain are unrealistic 4,18,19. Similar to exposure treatments for phobias and other anxiety disorders, in vivo exposure treatment for fear of pain involves identification and development of a personalized, graduated hierarchy of activities that typically elicit a fearful response, psychoeducation related to pain and fear-avoidance behaviors, and ultimately, slow and systematic exposure to activities related to the individual’s fear hierarchy 18.
In vivo exposure treatment for pain-avoidant behavior has demonstrated efficacy in improving pain, pain catastrophizing, and functional disability 20, and in decreasing pain-related fear as well as anxiety and depression 21.
OBT is not generally implemented as stand-alone psychotherapy for chronic pain conditions. Understanding operant-behavioral theory, however, is important for providers, patients and family members in order to avoid unconsciously reinforcing negative pain behaviors.
BEHAVIORAL ACTIVATION (BA):
Behavioral Activation is designed to increase the individual’s contact with positively rewarding activities. Specific progressive and measurable goals, in the form of pleasurable activities that are consistent with the patient’s desired lifestyle and motivations, are sequentially introduced. Although Behavioral Activation is usually employed as a specific CBT skill component, it can be used alongside other specific CBT skills such as cognitive restructuring, or, in selected cases, as stand-alone therapy (for example in individuals with social withdrawal due to chronic pain and/or depression).
The primary benefit of group therapy is to use the dynamics of the group to benefit each participant. In order to ensure that the group dynamics are optimized, participants must be willing and compliant, possess at least basic skills of social interaction, and not have personality traits that can adversely impact the group dynamics. Group therapy can also increase the efficiency of the therapist by treating multiple patients in one time slot. Other advantages of group therapy include affordability for patients and health-care payers.
- Support Groups: Support groups are the most popular approaches to group therapy. They are frequently led by patients or volunteer staff. They may be organized into physical groups or online virtual groups. In ideal circumstances, these groups can provide social and emotional support and improved self-esteem to poorly adapted chronic pain patients who often suffer from social isolation and pervasive negative thoughts and emotions, while also offering participants a forum for comparing experiences and sharing information. However, this forum does not offer an environment for structured learning of new coping skills and adaptive strategies, and may suffer from inadequate supervision and direction, or detrimental group dynamics.
- Cognitive-Behavioral Medicine Groups: are structured, time-limited CBT groups directed toward specific patients with chronic pain who can learn and function well in a group setting. Interventions employed typically include those fostered in individual CBT and may include mind-body interventions including relaxation, meditation, hypnosis or self-hypnosis, guided imagery, pacing activities, Tai Chi, Yoga and maintaining a pain diary. These groups are generally led by professionals who are active practitioners of CBT.
- Chronic Disease Self-Management Programs (CDSMP): CDSMP was developed by a team of researchers at Stanford University. It is based on the generic principles of the Arthritis Self-Management Program that is taught at community sites and designed to help patients with chronic disease develop self-management skills. It involves small groups of participants of mixed disease diagnoses and may include family members who choose to attend. Instruction and training are provided by a pair of certified community leaders who are often chronic disease patients themselves. Based on self-efficacy theory, it incorporates guided mastery of skills, through weekly sessions, with content that includes: addressing physical and psychologic effects of chronic disease (including pain fatigue, fear, anger, depression, anxiety, and frustration); adoption of exercise programs; use of cognitive symptom management techniques, such as guided relaxation and distraction; dietary/nutritional change; sleep management; judicious use of medications and community resources; communicating effectively with friends, family, care-givers and health-care professionals; health-related problem solving; and decision making 22.
The program content has been published in “Living a Healthy Life with Chronic Conditions”, which serves as a guide for participants. The implementation of the program is documented in a detailed protocol, Chronic Disease Self-Management Leader’s Manual 23.
CDSMP is an effective, low-cost self-management program that helps patients with chronic health conditions, including chronic pain, lead more fulfilling lives. There is strong evidence from peer-reviewed publications and program evaluations that participation in CDSMP workshops can improve physical and psychosocial outcomes and quality of life for people with chronic health conditions 24.
- Decreased pain and health-related distress
- Increased energy and less fatigue
- Increased physical activity
- Increased confidence and self-efficacy
- Decreased depression and anxiety
- Better communication with health-care providers
- Decreased social role limitations
- Increased confidence in managing chronic disease
- Proactive mindset
- Chronic Pain Self-Management Program (CPSMP): Initially developed by Sandra LeFort, PhD, MN, RN in 1996 at McGill University, Montreal, and later updated at Memorial University, St. John’s, Newfoundland, Canada, with Lisa Cardas, RN, the CPSMP was revised in 2008, in conjunction with Kate Lorig, DRPH and the staff of the Stanford Patient Education Research Center. It was revised again in 2015 when the book Living a Healthy Life with Chronic Pain was written to accompany the program. The group structure parallels CDSMP workshops, and outcomes are comparable to studies of CDSMP and other chronic pain programs reported in the literature
The efficacy of group psychotherapy in reducing psychological and physical distress accompanying chronic medical illness is well documented 25,26. Patients with a broad range of medical illnesses demonstrate improved compliance, reductions in somatic symptoms, anxiety and depression, and increased self-esteem 27.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
As stated above, there are numerous psychological interventions available for implementation in patients with chronic pain. The intractable nature of chronic pain may make adaptation difficult as attempts to control pain through conventional psychotherapeutic domains may ultimately become ineffectual, potentially contributing to greater psychological distress 29. Recent efforts have thus expanded the cognitive-behavioral model of pain intervention to address these issues, which has yielded two relatively newer treatment modalities: mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT). Unlike CBT, these approaches focus on fostering acceptance of chronic pain rather than emphasizing strategies for controlling pain, thereby improving emotional well-being and greater engagement in alternative pursuits that do not significantly amplify pain. Though these interventions both target acceptance of pain, they differ in their therapeutic implementation and approach to meditation and daily practice 4.
Distraction therapy employing Virtual Reality has been employed successfully in pediatric burn patients undergoing painful dressing changes. Distraction was associated with decreased activity in the cingulo-frontal cortex including orbitofrontal region, anterior cingulate cortex, preiaqeuductal gray (PAG) nucleus, and posterior thalamus. Higher cortical areas may exert a descending influence on PAG and posterior thalamus to modulate pain during distraction 28.
Guided motor imagery (GMI) is a modality that has become more widely implemented. Initially developed as a means to treat phantom limb pain, it has more recently been expanded to treat a number of other chronic pain conditions including complex regional pain syndrome. GMI posits that certain chronic pain states are a result of amplification of neural signaling, causing pain hypersensitivity or central sensitization that can also result in disrupted somatotropic processing within the body. GMI focuses on revamping neural organization or fostering cortical remapping of an aberrant system. There are typically three steps involved in GMI: left/right judgment training, motor imagery, and mirror therapy 29.
It is critically important to recognize that pain cannot be interpreted solely as an isolated objective sensory neurophysiologic event. It is equally, if not more impactfully, a perceptual experience that is unique to each individual. However, with the emergence of new technologies such as functional MRI (fMRI), functional networks in the brain intricately involved in the subjective (emotional, affective, motivational) aspects of pain, objective (sensory, discriminative) aspects of pain, as well as loci associated with pain processing and modulation, can now be objectively imaged. fMRI research has been instrumental in identifying the four regions of the brain (primary and secondary somatosensory cortex (S1 and S2), anterior cingulate cortex (ACC), and insula) that are consistently activated in pain states. As we learn more about fMRI, functional connectivity patterns could emerge as biomarkers for specific pain conditions 30.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Currently, it is not well-understood why some patients transition from acute to chronic pain and disability. One interesting area of research is genetics, and its contributory role in the development and experience of chronic pain. There are a number of published studies which suggest that genetics may play a pivotal role in how individuals experience and respond to pain and physical illness. Some of these studies suggest that specific genes are linked to various psychiatric and psychological disorders associated with chronic pain conditions 31. Other studies have identified various genetic mutations that result in aberrant voltage gated ion channels that affect how pain is transmitted from the peripheral nervous system 32.
It is evident that we have only just scratched the surface in terms of our current state of knowledge of the biological and genetic components of pain as well as the affective dimensions and cognitive appraisal inextricably intertwined with pain and other physical disorders complicated by co-morbid psychologic distress. With further research and understanding of these relationships, we can anticipate the emergence of more successful treatments and targets for intervention.
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- Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. (2014). Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs
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Original Version of the Topic
Armando S. Miciano, MD. Psychological factors affecting physical disorders Part 2: A general approach to treatment . Original Publication Date: 09/20/2014
Bosco Francisco Soares, MD
Nothing to Disclose
David Niumatalolo, MD
Nothing to Disclose