Applying dialectical behavior therapy to chronic pain: A case study
Authors: Linton Steven J. 
Published: December 2009

Abstract

Background and aims
Chronic pain patients often present with a host of psychological and somatic problems and are unable to work despite receiving traditional pain management. For example, it is common that patients with persistent pain also suffer from a variety of anxiety and depressive symptoms. Indeed, the regulation of emotions may be one important factor that is associated with the development of persistent pain. Dialectical behavior therapy, a form of cognitive-behavioral therapy, focuses on emotion regulation and has successfully addressed other complex problems. The objective of this case study was to test the feasibility of developing and applying a dialectical behavior therapy approach to chronic pain.

Methods

Feasibility study of n = 1: A 52-year-old adult suffering musculoskeletal pain, work disability, depression, and mood swings was offered therapy. She had not worked at her occupation for 10 years. An intervention was developed based on dialectical behavior therapy that included goal setting, validation, behavioral experiments and interoceptive exposure. Goals were developed with the client, based on her own values, and these were to: increase participation in previously enjoyable activities, not only reduce but also accept that some pain may remain, and, express and regulate emotions. Validation (understanding the patient’s situation) and psychoeducation were used to analyze the problem with the patient in focus. Function was approached by monitoring activities and conducting dialectical behavioral experiments where the patient systematically approached activities she no longer participated in (exposure). Emotional regulation followed a training program developed in dialectical behavior therapy designed to have people experience, express, and manage a variety of positive and negative emotions. In order to address the patient’s complaint that she avoided her own feelings as well as the pain, interoceptive exposure was introduced. After establishing calm breathing, the client was asked to focus attention on the negative feelings or pain as a way of de-conditioning the psychological responses to them. Therapy was conducted during 16 sessions over a six-month period.

Results
Improvements were seen on the main outcome variables. Pain intensity ratings dropped from 4.3 during the baseline to almost 0 at the end of treatment. Function increased as the patient participated in goal activities. Depression scores were decreased from 26 (Beck’s Depression Inventory) at pre treatment to 5 at follow-up, which falls within the normal range. Similarly, catastrophizing and fear decreased on standardized scales and fell within the range of a nonclinical population. Ratings indicated that acceptance of the pain increased over the course of therapy. Sleep improved and was also within the normal range according to scores on the Insomnia Severity Index. The patient reported seeking and obtaining employment as well. At the three-month follow-up improvements were maintained

Conclusions
This case shows that dialectical behavior therapy may be feasible for people suffering persistent pain with multiple problems such as pain, depression, and emotion regulation. However, since this is a case study, the validity of the findings has not yet been established. The positive results, however, warrant the further investigation of the application of these techniques to complex chronic pain cases.