Abstract
Chronic pain remains a serious healthcare challenge, particularly for older adults
who suffer substantial disability and are susceptible to serious risks from pain medications
and invasive procedures. Psychotherapy is a promising option for older adults with
chronic pain, since it does not contribute to medical or surgical risks. However,
standard psychotherapies for chronic pain, including cognitive-behavioral therapy
(CBT), acceptance and commitment therapy, and mindfulness-based interventions, produce
only modest and time-limited benefits for older adults. In this article, we describe
a novel, evidence-based psychological assessment and treatment approach for older
adults with chronic pain, including a detailed case example. The approach begins with
reviewing patients’ pain, psychosocial, and medical histories to elicit evidence of
a subtype of chronic pain called centralized (primary, nociplastic, or psychophysiologic)
pain, which is highly influenced and may even be caused by life stress, emotions,
and alterations in brain function. Patients then undertake a novel psychotherapy approach
called emotional awareness and expression therapy (EAET) that aims to reduce or eliminate
centralized pain by resolving trauma and emotional conflicts and learning healthy
communication of adaptive emotions. Our published preliminary clinical trial (n = 53)
indicated that EAET produced statistically significant and large effect size advantages
over CBT in pain reduction and marginally greater improvements in pain interference
than CBT for older adults with chronic musculoskeletal pain. Geriatric mental healthcare
providers may learn this assessment and treatment approach to benefit many of their
patients with chronic pain.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of Geriatric PsychiatryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Prevalence of chronic pain among adults in the United States.Pain. 2022; 163: e328-e332
- Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans.J Psychosom Res. 1997; 43: 379-389
- Identifying the activities affected by chronic nonmalignant pain in older veterans receiving primary care.J Am Geriatr Soc. 2005; 53: 687-694
- Prevalence and relevance of pain in older persons.Pain Med. 2012; 13: S23-S26
- Mortality among older adults with opioid use disorders in the Veteran's Health Administration, 2000–2011.Drug Alcohol Dependence. 2015; 147: 32-37
- Relationship of opioid use and dosage levels to fractures in older chronic pain patients.J Gen Intern Med. 2010; 25: 310-315
- Association between psychological interventions and chronic pain putcomes in older adults: a systematic review and meta-analysis.JAMA Intern Med. 2018; 178: 830-839
- Psychological therapy for centralized pain: an integrative assessment and treatment model.Psychosom Med. 2019; 81: 114-124
- Chronic pain: the role of learning and brain plasticity.Restor Neurol Neurosci. 2014; 32: 129-139
- Corticostriatal functional connectivity predicts transition to chronic back pain.Nat Neurosci. 2012; 15: 1117
- Pain and emotion: a biopsychosocial review of recent research.J Clin Psychol. 2011; 67: 942-968
IASP: International Association for the Study of Pain (IASP) Terminology, 2017. Available at: https://www.iasp-pain.org/resources/terminology/. Accessed January 13, 2022.
- Systematic review and synthesis of mechanism-based classification systems for pain experienced in the musculoskeletal system.Clin J Pain. 2020; 36: 793-812
- How long does a knee replacement last? a systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.Lancet. 2019; 393: 655-663
- How long does a hip replacement last? a systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.Lancet. 2019; 393: 647-654
- Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain.Pain Manag. 2021; 11: 325-332
- Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study.Am J Prev Med. 1998; 14: 245-258
- Adverse events in childhood and chronic widespread pain in adult life: results from the 1958 British birth cohort study.Pain. 2009; 143: 92-96
- Chronic pain types differ in their reported Prevalence of Post -Traumatic Stress Disorder (PTSD) and there is consistent evidence that chronic pain is associated with PTSD: an evidence-based structured systematic review.Pain Med. 2017; 18: 711-735
- Emotion regulation as a transdiagnostic factor underlying co-occurring chronic pain and problematic opioid use.Am Psychol. 2020; 75: 796-810
- The role of emotion regulation in chronic pain: a systematic literature review.J Psychosom Res. 2018; 107: 38-45
- Specific and general therapeutic mechanisms in cognitive behavioral treatment of chronic pain.J Consult Clin Psychol. 2015; 83: 1-11
- Anger inhibition and pain: conceptualizations, evidence and new directions.J Behav Med. 2008; 31: 259-279
- At the intersection of anger, chronic pain, and the brain: a mini-review.Neurosci Biobehav Rev. 2022; 135104558
- Emotional Awareness and Expression Therapy (EAET) achieves greater pain reduction than cognitive behavioral therapy (CBT) in older adults with chronic musculoskeletal pain: a preliminary randomized comparison trial.Pain Med. 2020; 21: 2811-2822
- Emotions matter: the role of emotional approach coping in chronic pain.Eur J Pain. 2020; 24: 1775-1784
- Emotional processing and its association to somatic symptom change in emotional awareness and expression therapy for somatic symptom disorder: a preliminary mediation investigation.Front Psychol. 2021; 12712518
- The cortical rhythms of chronic back pain.J Neurosci. 2011; 31: 13981-13990
- Beyond feeling: chronic pain hurts the brain, disrupting the default-mode network dynamics.J Neurosci. 2008; 28: 1398-1403
- Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain.J Neurosci. 2006; 26: 12165-12173
- Abnormal medial prefrontal cortex functional connectivity and its association with clinical symptoms in chronic low back pain.Pain. 2019; 160: 1308-1318
- Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: a randomized clinical trial.JAMA Psychiatry. 2021; 79: 13-23
- Deconstructing chronic low back pain in the older adult–step by step evidence and expert-based recommendations for evaluation and treatment. Part V: maladaptive coping.Pain Med. 2016; 17: 64-73
- Deconstructing chronic low back pain in the older adult-step by step evidence and expert-based recommendations for evaluation and treatment: Part VII: insomnia.Pain Med. 2016; 17: 851-863
- Deconstructing chronic low back pain in the older adult: step by step evidence and expert-based recommendations for evaluation and treatment: Part IV: depression.Pain Med. 2015; 16: 2098-2108
- Deconstructing chronic low back pain in the older adult-step by step evidence and expert-based recommendations for evaluation and treatment: Part IX: anxiety.Pain Med. 2016; 17: 1423-1435
- Deconstructing chronic low back pain in the older adult-step by step evidence and expert-based recommendations for evaluation and treatment: Part XI: dementia.Pain Med. 2016; 17: 1993-2002
- Chronic noncancer pain management and systemic racism: time to move toward equal care standards.J Pain Res. 2020; 13: 2825-2836
- The effect of perceived racial discrimination on bodily pain among older African American men.Pain Med. 2009; 10: 1341-1352
- Injustice appraisal, but not pain catastrophizing, mediates the relationship between perceived ethnic discrimination and depression and disability in low back pain.J Pain. 2020; 21: 582-592
- Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.Am J Neuroradiol. 2015; 36: 811-816
- Racism in pain medicine: we can and should do more.Mayo Clin Proc. 2021; 96: 1394-1400
- Emotional awareness and expression therapy for chronic pain: rationale, principles and techniques, evidence, and critical review.Curr Rheumatol Rep. 2019; 21: 30
- Emotional Awareness and Expression Therapy (EAET): a group-based treatment manual for patients with fibromyalgia and related centralized pain disorders (version 2).Wayne State University, Detroit, MI2012
- Psychoanalytic therapy: principles and application.Ronald Press, New York, NY1946
- Intensive short-term dynamic psychotherapy: selected papers of habib davanloo, md.Wiley, Hoboken, NJ2000
- Dissociation of sensory and affective dimensions of pain using hypnotic modulation.Pain. 1999; 82: 159-171
- Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial.Pain. 2017; 158: 2354-2363
- Internet-administered emotional awareness and expression therapy for somatic symptom disorder with centralized symptoms: a preliminary efficacy trial.Front Psychiatry. 2021; 12620359
- Future directions in psychological therapies for pain management.Pain Med. 2020; 21: 2624-2626
Article info
Publication history
Published online: July 29, 2022
Accepted:
July 26,
2022
Received in revised form:
July 22,
2022
Received:
March 1,
2022
Identification
Copyright
Published by Elsevier Inc. on behalf of American Association for Geriatric Psychiatry.