CLINICAL FACTOR

Clinical Factor and its Relevance to two Forms of Therapy

Clinical Factor and its Relevance to two Forms of Therapy

Interventions

Cognitive-behavioral therapy (CBT) interventions are often used as adjunct treatments with standard medical care to help patients with chronic illnesses better manage their pain and distress or improve function. We review the primary assumptions and the four essential components that underlie all CBT interventions. We then examine the outcomes produced by CBT interventions for patients with two chronic illnesses for which the source of pain is well understood (rheumatoid arthritis and osteoarthritis of the knee) and three disorders characterized by “medically unexplained” pain and other symptoms (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome).

We employed American Psychological Association criteria for empirically validated treatments to evaluate the CBT intervention outcomes. Using these criteria, we conclude that CBT is a well-established adjunct treatment for patients with rheumatoid arthritis and is probably efficacious for patients with knee osteoarthritis, chronic fatigue syndrome, and irritable bowel syndrome. However, CBT interventions must be considered as an experimental therapy for patients with fibromyalgia. The negative findings associated with CBT for fibromyalgia may be due to several factors such as high levels of psychiatric morbidity or abnormal pain sensitivity among the patients. It is necessary for investigators to devote effort to identifying the factors that account for poor CBT outcomes and to modify current CBT protocols to address these factors.

Patients with chronic illness regard pain as a major challenge to their quality of life. Pain is also a major determinant of patients' health behaviors. For example, among patients with rheumatoid arthritis (RA), pain is more important than physical or psychologic disability in explaining medication usage. Conversely, the higher frequency of refusals to undergo total joint replacement surgery among black patients, compared to white patients, with advanced knee osteoarthritis (OA) is highly associated with blacks' expectations of higher levels of postsurgical pain.

Pain also presents challenges to health-care providers. Because pain is a subjective experience, it cannot be measured directly or assessed in reference to a physiologic “gold standard.” Instead, health-care providers must make inferences regarding patients' subjective pain experiences on the basis of their verbal reports, overt motor behaviors (e.g., grimacing), or responses to various rating scales. However, patients' pain experiences and behaviors are influenced by numerous psychosocial factors (e.g., mood and cultural background) as well as by disease processes. Thus, effective treatment of pain associated with chronic illnesses often requires the efforts of interdisciplinary teams with expertise in medicine, psychology, pharmacology, physical modalities, and exercise.

In what follows we focus on the efficacy of cognitive-behavioral therapy (CBT) interventions for managing pain associated with chronic illnesses. These interventions are typically provided to patients by clinical psychologists in addition to standard medical care. We first discuss the rationale underlying CBT interventions and describe the major treatment components of these interventions. We then will review the literature regarding the efficacy of CBT interventions for managing pain associated with several chronic illnesses. These chronic illnesses are divided into two ...