Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model

Psychosom Med. Feb/Mar 2019;81(2):114-124. doi: 10.1097/PSY.0000000000000654.


Objective: Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed.

Methods: We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance/mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges.

Results: Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress.

Conclusions: This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Chronic Pain / diagnosis
  • Chronic Pain / therapy*
  • Humans
  • Psychotherapy / methods*
  • Psychotherapy / standards