0517 Integrated Cognitive Behavioral Therapy (CBT) and Mindfulness Group Treatment Protocol for Insomnia and Chronic Pain

Abstract Introduction Chronic pain and insomnia are highly comorbid, and CBT is a recommended treatment for both. CBT protocols that treat these conditions together, however, show improvements in sleep but not pain. As mindfulness, an acceptance-based approach, has been used successfully to treat chronic pain, integrating mindfulness into a combined CBT treatment protocol may help improve outcomes for chronic pain as well as insomnia. Methods An integrated CBT/Mindfulness weekly 6-session group protocol for chronic pain and insomnia was developed and piloted. Treatment components included education about pain neuroscience as well as sleep and circadian biology, relaxation, time-based pacing, tracking 24-hour time in bed, sleep compression, stimulus control, cognitive reframing, and mindfulness. Pre-post measures evaluating insomnia symptoms, sleep hygiene, pain acceptance, pain catastrophizing, and unhelpful beliefs about sleep and pain were analyzed using frequency analyses and paired sample t-tests. Results Two groups were completed for a total of 16 participants, 94% of whom attended at least 5 sessions. Average age was 56 years, 75% of the sample was female, 88% were White, 6% Asian, and 6% Latino. Post-treatment outcomes showed significant improvement in insomnia symptoms (ISI Mdiff=6.6, SDdiff=5.3, p=.01, ES=1.2), sleep hygiene (SHI Mdiff=3.8, SDdiff=4.6, p=.02, ES=.83), pain acceptance (CPAQ Mdiff=5.2, SDdiff=7.8, p=.03, ES=.67), pain catastrophizing (PCS Mdiff=5.1, SDdiff=7.5, p=.03, ES=.68), and unhelpful beliefs about sleep (DBAS Mdiff=31.4, SDdiff=21.2, p=.009, ES=1.5) and pain (PBAS Mdiff=11.6, SDdiff=10.7, p=.02, ES=1.1). Conclusion An integrated CBT/Mindfulness group protocol for chronic pain and insomnia showed significant improvements in post-treatment sleep and pain measures. As previous combined CBT-only protocols showed pre-post improvement in sleep but not pain, the current study demonstrates that including mindfulness might improve outcomes for chronic pain. Future studies should compare CBT protocols for chronic pain and insomnia with and without mindfulness to determine the clinical benefits of including an acceptance-based component. Support Poster presented as part of collaborative conversation with Skye Margolies, PhD, Department of Anesthesiology, University of North Carolina School of Medicine.

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0530 Hybrid Cognitive Behavior Therapy for Insomnia (CBT-I) and Acceptance and Commitment Therapy (ACT) Group Treatment Model for Insomnia and Chronic Pain

SLEEP ◽

10.1093/sleep/zsaa056.527 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A202-A203

Author(s):

S Ochsner Margolies

Keyword(s):

Chronic Pain ◽

Group Treatment ◽

Behavioral Activation ◽

Pain Catastrophizing ◽

Current Treatment ◽

Sleep Diary ◽

Present Moment ◽

Pain Acceptance ◽

Pain Outcomes ◽

Insomnia Symptoms

Abstract Introduction Insomnia is a common complaint for individuals with chronic pain. CBT-I as an intervention for these patients shows strong improvement in sleep but not consistently in pain outcomes. Current treatment approaches for chronic pain focus increasingly on acceptance-based interventions. Integrating ACT into a CBT-I group protocol has the potential to optimize both sleep and pain outcomes. Methods A hybrid CBT-I/ACT 6-session weekly group protocol for chronic pain and insomnia was developed and piloted. CBT-I components included sleep education, stimulus control, and sleep restriction. ACT components included cognitive defusion, self-as-context, present moment awareness, mindfulness, and values-guided behavioral activation. Pre-post measures assessing insomnia symptoms, sleep parameters based on sleep diary, sleep catastrophizing, pain catastrophizing, pain acceptance, beliefs about pain and sleep, depression, and anxiety were analyzed using frequency analyses and paired sample t-tests. Results Group participants (4) recruited from an outpatient pain management clinic were on average 57 years old, 100% female and 75% White. Post-treatment, patients reported significantly improved insomnia symptoms (ISI Mdiff=5.8, SDdiff=3.9, p < .05, ES=1.5), sleep efficiency (SE, Mdiff=16%, SDdiff= 10%, p = .05, ES=1.5), pain catastrophizing (PCS Mdiff=7.8, SDdiff=4.6, p < .05, ES=1.6), pain acceptance (CPAQ Mdiff=11.5, SDdiff=7.5, p = .05, ES=1.5), beliefs about the relationship between pain and sleep (PBAS Mdiff=2.3, SDdiff=1.3, p < .05, ES=1.8) and anxiety (GAD-7 Mdiff=3.3, SDdiff=2.1, p < .05, ES = 1.6). Conclusion Hybrid CBT-I/ACT group protocol for chronic pain and insomnia showed significant improvements in sleep and, more importantly, pain outcomes. This pilot study demonstrates the benefits of incorporating an ACT approach to optimize pain as well as sleep outcomes. Future efforts will continue to refine the CBT-I/ACT protocol in anticipation of conducting a dismantling study to determine the clinical benefits of adding an ACT framework to the CBT-I model. Support NA

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361 Relative Effectiveness of Cognitive Behavioral Therapy and its Components in Improving Insomnia Symptoms in Older Adults

SLEEP ◽

10.1093/sleep/zsab072.360 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A144-A144

Author(s):

Kathleen O’Hora ◽

Beatriz Hernandez ◽

Laura Lazzeroni ◽

Jamie Zeitzer ◽

Leah Friedman ◽

...

Keyword(s):

Older Adults ◽

Cognitive Behavioral Therapy ◽

Behavioral Therapy ◽

Sleep Onset ◽

Post Treatment ◽

Cognitive Behavioral ◽

Sleep Onset Latency ◽

Significant Group ◽

Time Interaction ◽

Insomnia Symptoms

Abstract Introduction The prevalence of insomnia complaints in older adults is 30–48%, compared to 10–15% in the general population. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a first-line, non-pharmacological sleep treatment for Insomnia. However, the relative impact of Behavioral (BT) and Cognitive (CT) components compared to that of CBT-I in older adults is unknown. Methods 128 older adults with insomnia were randomized to receive CBT-I, BT, or CT. Sleep diaries and the Insomnia Severity Index (ISI) were collected pre- and post-treatment and at a 6-month follow-up. We conducted split-plot linear mixed models with age and sex as covariates to assess within and between subject changes to test effects of group, time, and their interaction on ISI, sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), time in bed (TIB), sleep efficiency (SE), and percent of treatment responders (ISI decrease>7) and remitters (ISI<8). Effect size (d) was calculated by dividing the difference between means by the root-mean-squared error of the mixed effects model. Results All treatments lead to a significant improvement across outcome measures at post-treatment (p’s<0.001) and 6-months (p’s<0.01), with the exception of TIB, response, and remission. For TIB, there was a significant Group x Time interaction (p<0.001): while all treatments significantly reduced TIB post-treatment relative to baseline, CBT-I (p<0.001,d=-2.26) and BT (p<0.001,d=-1.59) performed significantly better than CT (p=0.003, d=-0.68). In contrast, at 6-months CBT-I (p<0.001,d=-1.16) performed significantly better at reducing TIB than CT (p=0.195,d=-0.24) or BT (p=0.023,d=-0.61) relative to baseline. There was also a non-significant trend for a Group x Time interaction for remission status (p=0.062). Whereas, the percentage of remitters within all groups post-treatment did not differ from chance (p>0.234), at 6 months, the percentage of remitters was significantly higher than chance in CBT-I (73.63%,p=0.026) and BT (78.08%,p=0.012), but not CT (47.85%,p=0.826). There were no other significant time or interaction effects (all p>0.05). Conclusion CBT-I and its components are effective in improving subjective insomnia symptoms in older adults. Evidence suggests CBT-I may be superior to either CT or BT alone in improving TIB in older adults. Support (if any) NIMHR01MH101468; MIRECC at VAPAHCS

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Process-outcome associations in an interdisciplinary treatment for chronic pain and comorbid mental disorders based on Acceptance and Commitment Therapy

Pain Medicine ◽

10.1093/pm/pnab102 ◽

2021 ◽

Author(s):

Ludwig Ohse ◽

Ronald Burian ◽

Eric Hahn ◽

Hannah Burian ◽

Thi Minh Tam Ta ◽

...

Keyword(s):

Chronic Pain ◽

Mental Disorders ◽

Clinical Outcomes ◽

Acceptance And Commitment Therapy ◽

Psychological Flexibility ◽

Post Treatment ◽

Interdisciplinary Treatment ◽

Pain Acceptance ◽

Acceptance And Commitment ◽

Comorbid Mental Disorders

Abstract Objective Numerous studies support the effectiveness of Acceptance and Commitment Therapy (ACT) for chronic pain, yet little research has been conducted about its underlying mechanisms of change, especially regarding patients with comorbid mental disorders. The present investigation addressed this issue by examining associations of processes targeted by ACT (pain acceptance, mindfulness, psychological flexibility) and clinical outcomes (pain intensity, somatic symptoms, physical health, mental health, depression, general anxiety). Subjects Participants were 109 patients who attended an ACT-based interdisciplinary treatment program for chronic pain and comorbid mental disorders in a routine care psychiatric day hospital. Methods Pre- to post-treatment differences in processes and outcomes were examined with Wilcoxon signed-rank tests and effect size r. Associations between changes in processes and changes in outcomes were analyzed with correlation and multiple regression analyses. Results Pre- to post-treatment effect sizes were mostly moderate to large (r between |0.21| and |0.62|). Associations between changes in processes and changes in outcomes were moderate to large for both, bivariate correlations (r between |0.30| and |0.54|) and shared variances accounting for all three processes combined (R2 between 0.21 and 0.29). Conclusion The present investigation suggests that changes in pain acceptance, mindfulness and psychological flexibility are meaningfully associated with changes in clinical outcomes. It provides evidence on particular process-outcome associations that had not been investigated in this way before. The focus on comorbid mental disorders informs clinicians about a population of chronic pain patients that often has a severe course of illness and has seldom been studied.

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, Positive CBT: Individual and Group Treatment Protocols for Positive Cognitive Behavioral Therapy

10.1027/00578-000 ◽

2021 ◽

Author(s):

Fredrike Bannink ◽

Nicole Geschwind

Keyword(s):

Group Treatment ◽

Behavioral Therapy ◽

Treatment Protocol ◽

Cognitive Behavioral ◽

Individual Treatment ◽

Treatment Protocols ◽

Self Compassion ◽

The Individual ◽

And Behavior ◽

Solution Focused

Positive CBT integrates positive psychology and solution-focused brief therapy within a cognitive-behavioral framework. It focuses not on reducing what is wrong, but on building what's right. This fourth wave CBT, developed by Fredrike Bannink, is now being applied worldwide for various psychological disorders. An introductory chapter explores the three approaches incorporated in positive CBT. Next, the book presents research into the individual treatment protocol for use with clients with major depressive disorder by Nicole Geschwind and colleagues at Maastricht University. The last chapters describe two 8-session treatment protocols for positive CBT, one for use with individuals and one for use with groups. The treatment protocols provide therapists with a step-by-step guide on how to apply positive CBT with individual clients and in group therapy. This approach goes beyond symptom reduction and instead focuses on the client’s preferred future, on finding exceptions to problems and identifying competencies. Topics such as self-compassion, optimism, gratitude, and behavior maintenance are explored. In addition to the protocols, two workbooks for clients are available online for download by therapists.

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MECHANISM OF ACTION: AGE DIFFERENCES IN RESPONSE TO ACCEPTANCE AND COMMITMENT THERAPY FOR CHRONIC PAIN

Innovation in Aging ◽

10.1093/geroni/igz038.2979 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S809-S809

Author(s):

Julie L Wetherell ◽

Matthew Herbert ◽

Niloofar Afari

Keyword(s):

Older Adults ◽

Chronic Pain ◽

Acceptance And Commitment Therapy ◽

Behavioral Therapy ◽

Pain Interference ◽

Younger Adults ◽

Pain Acceptance ◽

Commitment Therapy ◽

Acceptance And Commitment

Abstract A recent randomized comparison of Acceptance and Commitment Therapy (ACT) vs. Cognitive-Behavioral Therapy for chronic pain found a clear age interaction effect, such that older adults benefitted more from ACT. In a subsequent study comparing ACT delivered in person to ACT delivered via telehealth to a sample of veterans (N=128, mean age 51.9, SD 13.3, range 25-89), we found no significant age by modality interactions, suggesting that older veterans responded as well as younger people did to telehealth delivery. Consistent with our previous findings, we found a trend for older adults to experience greater reduction in pain interference (p = .051) and significantly greater reduction in pain severity (p = .001) than younger adults following ACT. In younger veterans, change in pain acceptance from baseline to posttreatment was related to change in pain interference from baseline to 6-month follow-up (r = -.38), but change in pain interference from baseline to posttreatment was not related to change in pain acceptance from baseline to follow-up (r = .14), suggesting that, consistent with the ACT model, increased pain acceptance at posttreatment was related to reduced pain interference at follow-up. By contrast, in older veterans, both correlations were significant and of comparable magnitude (rs = -.43 and -.46, respectively), providing no support for the idea that change in pain acceptance drove change in pain interference. Overall, our findings suggest that ACT may work better in older adults with chronic pain than in younger adults, but via a different mechanism.

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Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Journal of Clinical Medicine ◽

10.3390/jcm8091373 ◽

2019 ◽

Vol 8 (9) ◽

pp. 1373 ◽

Cited By ~ 3

Author(s):

Probst ◽

Jank ◽

Dreyer ◽

Seel ◽

Wagner ◽

...

Keyword(s):

Chronic Pain ◽

Pain Intensity ◽

Pain Perception ◽

Rating Scale ◽

Post Treatment ◽

Interdisciplinary Treatment ◽

Binary Logistic Regression Analysis ◽

Pain Acceptance ◽

Pain Outcomes ◽

The Impact

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = -0.19 (SE = 0.08); T = -2.44; p = 0.017) . Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

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The “What If” and “Yes But” Syndrome

Psychological and Psychiatric Issues in Patients with Chronic Pain ◽

10.1093/med/9780197544631.003.0010 ◽

2021 ◽

pp. 79-86

Author(s):

Daniel M. Doleys ◽

Nicholas D. Doleys

Keyword(s):

Chronic Pain ◽

Treatment Outcomes ◽

Pain Catastrophizing ◽

Behavioral Therapy ◽

Office Visit ◽

Positive Outcome ◽

Definitive Diagnosis ◽

Critical Area ◽

Pain Medications ◽

Frustration Level

Repeated requests for a definitive diagnosis, prognosis, and reassurance as to the positive outcome of a therapy made by some patients with chronic pain can be very exhausting to both patient and clinician—especially when it is clear that no amount of information will be satisfactory. The practitioner can easily feel like be asked to be a psychic or fortune teller. Pain catastrophizing (PC) has emerged as critical area of study. PC has been linked pain intensity, decreased function, and treatment outcomes, including the effect of pain medications such as opioids. It is most effectively addressed by the use of cognitive-behavioral therapy procedures. Learning how to apply these strategies in the context of the typical office visit can reduce the frustration level of the clinician and patient. In more severe cases, referral to behavioral specialist may to advisable.

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Depressive symptoms and pain evaluations among persons with chronic pain: Catastrophizing, but not pain acceptance, shows significant effects

Pain ◽

10.1016/j.pain.2009.08.030 ◽

2009 ◽

Vol 147 (1) ◽

pp. 147-152 ◽

Cited By ~ 36

Author(s):

Elizabeth J. Richardson ◽

Timothy J. Ness ◽

Daniel M. Doleys ◽

James H. Baños ◽

Leanne Cianfrini ◽

...

Keyword(s):

Chronic Pain ◽

Depressive Symptoms ◽

Pain Catastrophizing ◽

Pain Acceptance

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Pain Catastrophizing and Pain Self-Efficacy Mediate Interdisciplinary Pain Rehabilitation Program Outcomes at Posttreatment and Follow-Up

Pain Medicine ◽

10.1093/pm/pnab271 ◽

2021 ◽

Author(s):

Matthew E Schumann ◽

Brandon J Coombes ◽

Keith E Gascho ◽

Jennifer R Geske ◽

Mary C McDermott ◽

...

Keyword(s):

Chronic Pain ◽

Cognitive Behavioral Therapy ◽

Self Efficacy ◽

Pain Catastrophizing ◽

Behavioral Therapy ◽

Rehabilitation Program ◽

Cognitive Behavioral ◽

Pain Outcomes ◽

Pain Symptoms

Abstract Background Decreasing pain catastrophizing and improving self-efficacy to self-manage chronic pain symptoms are important treatment targets in the context of interdisciplinary cognitive behavioral therapy for chronic pain. Greater pain catastrophizing has been shown to be associated with greater impact of pain symptoms on functioning, while conversely, greater pain self-efficacy has been associated with lower pain intensity and lower levels of disability. Objective To prospectively evaluate interdisciplinary cognitive behavioral therapy for pain outcomes, as well as to the mediating effects of both pain catastrophizing and pain self-efficacy on outcome. Methods Participants were 315 patients with chronic pain between April 2017 and April 2018 who completed a three-week interdisciplinary pain rehabilitation program. Pain severity, pain interference, pain catastrophizing, pain self-efficacy, quality of life, and depressive symptom questionnaires, and measures of physical performance were assessed at pre- and posttreatment. Follow-up questionnaires were returned by 163 participants. Effect size and reliable change analyses were conducted from pre- to posttreatment and pretreatment to 6-month follow-up. Mediation analyses were conducted to determine the mediating effect of pain catastrophizing and pain self-efficacy on pain outcome. Results Significant improvements from pre- to posttreatment in pain outcomes were observed, and over 80% evidenced reliable change in at least one pain-relevant measure. Pain catastrophizing and pain self-efficacy mediated the relationship between changes in pain outcomes. Conclusions Interdisciplinary pain rehabilitation is an effective treatment and decreasing pain catastrophizing and increasing pain self-efficacy can influence maintenance of treatment gains.

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0528 Insomnia as a Mechanism for Improvement in Alcohol Problems Among Young Adults

SLEEP ◽

10.1093/sleep/zsaa056.525 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A202-A202

Author(s):

M Miller ◽

L B Freeman ◽

C J Park ◽

N Hall ◽

P K Sahota ◽

...

Keyword(s):

Young Adults ◽

Significant Interaction ◽

Heavy Drinking ◽

Sleep Hygiene ◽

Alcohol Problems ◽

Post Treatment ◽

Significant Group ◽

Alcohol Related Problems ◽

Insomnia Symptoms

Abstract Introduction More than half of heavy-drinking young adults report symptoms of insomnia, which have been associated with alcohol-related problems. This study examined improvement in insomnia (via Cognitive Behavioral Therapy for Insomnia; CBT-I) as a mechanism for improvement in alcohol-related problems. Methods Fifty-six heavy-drinking young adults with insomnia (ages 18-30y) were randomized to CBT-I (n=28) or single-session sleep hygiene control (SH; n=28). Of those, 43 (77%) completed post-treatment (24 SH, 19 CBT-I) and 48 (86%) completed 1-month follow-up (25 SH, 23 CBT-I). Multiple imputation was used to estimate missing data. Treatment outcomes were assessed using multilevel models. Mediation was tested using bootstrapped confidence intervals for indirect effects in the PROCESS macro. Results CBT-I participants reported greater decreases in insomnia severity than those in the sleep hygiene group [group X time interaction, F(2,59)=11.29, p<.001], both post-treatment and at 1-month follow-up. Both groups decreased significantly in diary-assessed sleep quality [time, F(2,55)=40.30, p<.001], with a marginally significant interaction in favor of the CBT-I group [F(2,55)=2.69, p=.08]. There were no significant group by time interactions in the prediction of actigraphy-assessed sleep variables, although again, there was a marginally significant interaction in the prediction of actigraphy-assessed sleep efficiency [F(2,66)=2.75, p=.07]. Both groups reported significant decreases in drinking quantity over time [time, F(2,58=13.88, p<.001]. However, CBT-I participants reported greater decreases in alcohol-related consequences than those in the sleep hygiene group [F(2,67)=4.13, p=.02]. In the mediation model, CBT-I did not have a direct effect on change in alcohol-related consequences (B=1.49, SE=1.06, 95%CI=-0.65, 3.62); however, it influenced change in 1-month alcohol-related consequences indirectly through its influence on post-treatment insomnia symptoms (B=-1.09, SE=0.57, 95%CI=-2.30, -0.05). Conclusion CBT-I is effective in treating insomnia among heavy-drinking young adults and may be associated with reductions in alcohol-related problems due to its impact on insomnia symptoms. Support This work was supported by funding from the University of Missouri System Research Board Office (PI Miller). Mary Beth Miller’s contribution to this project was also supported by the National Institute on Alcohol Abuse and Alcoholism [grant number K23AA026895].

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