Behavioral And Relaxation Approaches Into The Treatment Of
Chronic Pain And Insomnia|
NIH Technology Statement Online
What Behavioral and Relaxation Approaches Are Used for Conditions Such as Chronic Pain and Insomnia?
How Successful Are These Approaches?
How Do These Approaches Work?
Are There Barriers To the Appropriate Integration of These Approaches Into Health Care?
What Are the Significant Issues for Future Research and Applications?
About the NIH Consensus Development Program
Objective. To provide physicians with a responsible
assessment of the integration of behavioral and relaxation
approaches into the treatment of chronic pain and insomnia.
Participants. A non-Federal, nonadvocate, 12-member panel
representing the fields of family medicine, social medicine,
psychiatry, psychology, public health, nursing, and epidemiology.
In addition, 23 experts in behavioral medicine, pain medicine,
sleep medicine, psychiatry, nursing, psychology, neurology, and
behavioral and neurosciences presented data to the panel and a
conference audience of 528.
Evidence. The literature was searched through Medline and
an extensive bibliography of references was provided to the panel
and the conference audience. Experts prepared abstracts with
relevant citations from the literature. Scientific evidence was
given precedence over clinical anecdotal experience.
Assessment Process. The panel, answering predefined
questions, developed their conclusions based on the scientific
evidence presented in open forum and the scientific literature.
The panel composed a draft statement that was read in its
entirety and circulated to the experts and the audience for
comment. Thereafter, the panel resolved conflicting
recommendations and released a revised statement at the end of
the conference. The panel finalized the revisions within a few
weeks after the conference.
Conclusions. A number of well-defined behavioral and
relaxation interventions now exist and are effective in the
treatment of chronic pain and insomnia. The panel found strong
evidence for the use of relaxation techniques in reducing chronic
pain in a variety of medical conditions as well as strong
evidence for the use of hypnosis in alleviating pain associated
with cancer. The evidence was moderate for the effectiveness of
cognitive-behavioral techniques and biofeedback in relieving
chronic pain. Regarding insomnia, behavioral techniques,
particularly relaxation and biofeedback, produce improvements in
some aspects of sleep, but it is questionable whether the
magnitude of the improvement in sleep onset and total sleep time
is clinically significant.
Chronic pain and insomnia afflict millions of Americans.
Despite the acknowledged importance of psychosocial and
behavioral factors in these disorders, treatment strategies have
tended to focus on biomedical interventions such as drugs and
surgery. The purpose of this conference was to examine the
usefulness of integrating behavioral and relaxation approaches
with biomedical interventions in clinical and research settings
to improve the care of patients with chronic pain and
Assessments of more consistent and effective integration of
these approaches required the development of precise definitions
of the most frequently used techniques, which include relaxation,
meditation, hypnosis, biofeedback (BF), and cognitive-behavioral
therapy (CBT). It was also necessary to examine how these
approaches have been previously used with medical therapies in
the treatment of chronic pain and insomnia and to evaluate the
efficacy of such integration to date.
To address these issues, the Office of Alternative Medicine
and the Office of Medical Applications of Research, National
Institutes of Health, convened a Technology Assessment Conference
on Integration of Behavioral and Relaxation Approaches into the
Treatment of Chronic Pain and Insomnia. The conference was
cosponsored by the National Institute of Mental Health, the
National Institute of Dental Research, the National Heart, Lung,
and Blood Institute, the National Institute on Aging, the
National Cancer Institute, the National Institute of Nursing
Research, the National Institute of Neurological Disorders and
Stroke, and the National Institute of Arthritis and
Musculoskeletal and Skin Diseases.
This technology assessment conference (1) reviewed data on the
relative merits of specific behavioral and relaxation
interventions and identified biophysical and psychological
factors that might predict the outcome of applying these
techniques and (2) examined the mechanisms by which behavioral
and relaxation approaches could lead to greater clinical
The conference brought together experts in behavioral
medicine, pain medicine, sleep medicine, psychiatry, nursing,
psychology, neurology, behavioral science, and neuroscience as
well as representatives from the public. After 1-1/2 days of
presentations and audience discussion, an independent, non-
Federal panel weighed the scientific evidence and developed a
draft statement that addressed the following five questions:
- What behavioral and relaxation approaches are used for
conditions such as chronic pain and insomnia?
- How successful are these approaches?
- How do these approaches work?
- Are there barriers to the appropriate integration of these
approaches into health care?
- What are the significant issues for future research and
The suffering and disability from these disorders result in a
heavy burden for individual patients, their families, and their
communities. There is also a burden to the Nation in terms of
billions of dollars lost as a consequence of functional
impairment. To date, conventional medical and surgical
approaches have failed&emdash;at considerable expense&emdash;to
adequately address these problems. It is hoped that this
Consensus Statement, which is based on rigorous examination of
current knowledge and practice and makes recommendations for
research and application, will help reduce suffering and improve
the functional capacity of affected individuals.
What Behavioral and Relaxation Approaches Are Used for Conditions Such as Chronic Pain and Insomnia?
Pain is defined by the International Association for the Study
of Pain as an unpleasant sensory experience associated with
actual or potential tissue damage or described in terms of such
damage. It is a complex, subjective, perceptual phenomenon with
a number of contributing factors that are uniquely experienced by
each individual. Pain is typically classified as acute, cancer-
related, and chronic nonmalignant. Acute pain is associated with
a noxious event. Its severity is generally proportional to the
degree of tissue injury and is expected to diminish with healing
and time. Chronic nonmalignant pain frequently develops
following an injury but persists long after a reasonable period
of healing. Its underlying causes are often not readily
discernible, and the pain is disproportionate to demonstrable
tissue damage. It is frequently accompanied by alteration of
sleep; mood; and sexual, vocational, and avocational
Insomnia may be defined as a disturbance or perceived
disturbance of the usual sleep pattern of the individual that has
troublesome consequences. These consequences may include daytime
fatigue and drowsiness, irritability, anxiety, depression, and
somatic complaints. Categories of disturbed sleep are (1)
inability to fall asleep, (2) inability to maintain sleep, and
(3) early awakening.
A variety of behavioral and relaxation approaches are used for
conditions such as chronic pain and insomnia. The specific
approaches that were addressed in this Technology Assessment
Conference were selected using three important criteria. First,
somatically directed therapies with behavioral components (e.g.,
physical therapy, occupational therapy, acupuncture) were not
considered. Second, the approaches were drawn from those
reported in the scientific literature. Many commonly used
behavioral approaches are not specifically incorporated into
conventional medical care. For example, religious and spiritual
approaches, which are the most commonly used health-related
actions by the U.S. population, were not considered in this
conference. Third, the approaches are a subset of those
discussed in the literature and represent those selected by the
conference organizers as most commonly used in clinical settings
in the United States. Several commonly used clinical
interventions such as music, dance, recreational, and art
therapies were not addressed.
Relaxation techniques are a group of behavioral therapeutic
approaches that differ widely in their philosophical bases as
well as in their methodologies and techniques. Their primary
objective is the achievement of nondirected relaxation, rather
than direct achievement of a specific therapeutic goal. They all
share two basic components: (1) repetitive focus on a word,
sound, prayer, phrase, body sensation, or muscular activity and
(2) the adoption of a passive attitude toward intruding thoughts
and a return to the focus. These techniques induce a common set
of physiologic changes that result in decreased metabolic
activity. Relaxation techniques may also be used in stress
management (as self-regulatory techniques) and have been divided
into deep and brief methods.
Deep methods include autogenic training, meditation, and
progressive muscle relaxation (PMR). Autogenic training consists
of imagining a peaceful environment and comforting bodily
sensations. Six basic focusing techniques are used: heaviness
in the limbs, warmth in the limbs, cardiac regulation, centering
on breathing, warmth in the upper abdomen, and coolness in the
forehead. Meditation is a self-directed practice for relaxing
the body and calming the mind. A large variety of meditation
techniques are in common use; each has its own proponents.
Meditation generally does not involve suggestion, autosuggestion,
or trance. The goal of mindfulness meditation is development of
a nonjudgmental awareness of bodily sensations and mental
activities occurring in the present moment. Concentration
meditation trains the person to passively attend to a bodily
process, a word, and/or a stimulus. Transcendental meditation
focuses on a "suitable" sound or thought (the mantra) without
attempting to actually concentrate on the sound or thought.
There are also many movement meditations, such as yoga and the
walking meditation of Zen Buddhism. PMR focuses on reducing
muscle tone in major muscle groups. Each of 15 major muscle
groups is tensed and then relaxed in sequence.
The brief methods, which include self-control relaxation,
paced respiration, and deep breathing, generally require less
time to acquire or practice and often represent abbreviated forms
of a corresponding deep method. For example, self-control
relaxation is an abbreviated form of PMR. Autogenic training may
be abbreviated and converted to a self-control format. Paced
respiration teaches patients to maintain slow breathing when
anxiety threatens. Deep breathing involves taking several deep
breaths, holding them for 5 seconds, and then exhaling
Hypnotic techniques induce states of selective attentional
focusing or diffusion combined with enhanced imagery. They are
often used to induce relaxation and also may be a part of CBT.
The techniques have pre- and postsuggestion components. The
presuggestion component involves attentional focusing through the
use of imagery, distraction, or relaxation, and has features that
are similar to other relaxation techniques. Subjects focus on
relaxation and passively disregard intrusive thoughts. The
suggestion phase is characterized by introduction of specific
goals; for example, analgesia may be specifically suggested. The
postsuggestion component involves
continued use of the new behavior following termination of
hypnosis. Individuals vary widely in their hypnotic
susceptibility and suggestibility, although the reasons for these
differences are incompletely understood.
BF techniques are treatment methods that use monitoring
instruments of various degrees of sophistication. BF techniques
provide patients with physiologic information that allows them to
reliably influence psychophysiological responses of two kinds:
(1) responses not ordinarily under voluntary control and (2)
responses that ordinarily are easily regulated, but for which
regulation has broken down. Technologies that are commonly used
include electromyography (EMG BF), electroencephalography,
thermometers (thermal BF), and galvanometry (electrodermal-BF).
BF techniques often induce physiological responses similar to
those of other relaxation techniques.
CBT attempts to alter patterns of negative thoughts and
dysfunctional attitudes in order to foster more healthy and
adaptive thoughts, emotions, and actions. These interventions
share four basic components: education, skills acquisition,
cognitive and behavioral rehearsal, and generalization and
maintenance. Relaxation techniques are frequently included as a
behavioral component in CBT programs. The specific programs used
to implement the four components can vary considerably. Each of
the aforementioned therapeutic modalities may be practiced
individually, or they may be combined as part of multimodal
approaches to manage chronic pain or insomnia.
Relaxation and Behavioral Techniques for Insomnia
Relaxation and behavioral techniques corresponding to those
used for chronic pain may also be used for specific types of
insomnia. Cognitive relaxation, various forms of BF, and PMR may
all be used to treat insomnia. In addition, the following
behavioral approaches are generally used to manage insomnia:
- Sleep hygiene, which involves educating patients about
behaviors that may interfere with the sleep process, with the
hope that education about maladaptive behaviors will lead to
- Stimulus control therapy, which seeks to create and protect
conditioned association between the bedroom and sleep.
Activities in the bedroom are restricted to sleep and sex.
- Sleep restriction therapy, in which patients provide a sleep
log and are then asked to stay in bed only as long as they think
they are currently sleeping. This usually leads to sleep
deprivation and consolidation, which may be followed by a gradual
increase in the length of time in bed.
- Paradoxical intention, in which the patient is instructed not
to fall asleep, with the expectation that efforts to avoid sleep
will in fact induce it.
How Successful Are These Approaches?
A plethora of studies using a range of behavioral and
relaxation approaches to treat chronic pain is reported in the
literature. The measures of success reported in these studies
depend on the rigor of the research design, the population
studied, the length of followup, and the outcome measures
identified. As the number of well-designed studies using a
variety of behavioral and relaxation techniques grows, the use of
meta-analysis as a means of demonstrating overall effectiveness
One carefully analyzed review of studies on chronic pain,
including cancer pain, was prepared under the auspices of the
U.S. Agency for Health Care Policy and Research (AHCPR) in 1990.
A great strength of the report was the careful categorization of
the evidential basis of each intervention. The categorization
was based on design of the studies and consistency of findings
among the studies. These properties led to the development of a
4-point scale that ranked the evidence as strong, moderate, fair,
or weak; this scale was used by the panel to evaluate the AHCPR
Evaluation of behavioral and relaxation interventions for
chronic pain reduction in adults found the following:
- Relaxation: The evidence is strong for the effectiveness of
this class of techniques in reducing chronic pain in a variety of
- Hypnosis: The evidence supporting the effectiveness of
hypnosis in alleviating chronic pain associated with cancer seems
strong. In addition, the panel was presented with other data
suggesting the effectiveness of hypnosis in other chronic pain
conditions, which include irritable bowel syndrome, oral
mucositis, temporomandibular disorders, and tension
- CBT: The evidence was moderate for the usefulness of CBT in
chronic pain. In addition, a series of eight well-designed
studies found CBT superior to placebo and to routine care for
alleviating low back pain and both rheumatoid arthritis and
osteoarthritis-associated pain, but inferior to hypnosis for oral
mucositis and to EMG BF for tension headache.
- BF: The evidence is moderate for the effectiveness of BF in
relieving many types of chronic pain. Data were also reviewed
showing EMG BF to be more effective than psychological placebo
for tension headache but equivalent in results to relaxation.
For migraine headache, BF is better than relaxation therapy and
better than no treatment, but superiority to psychological
placebo is less clear.
- Multimodal Treatment: Several meta-analyses examined the
effectiveness of multimodal treatments in clinical settings. The
results of these studies indicate a consistent positive effect of
these programs on several categories of regional pain. Back and
neck pain, dental or facial pain, joint pain, and migraine
headaches have all been treated effectively.
Although relatively good evidence exists for the efficacy of
several behavioral and relaxation interventions in the treatment
of chronic pain, the data are insufficient to conclude that one
technique is usually more effective than another for a given
condition. For any given individual patient, however, one
approach may indeed be more appropriate than another.
Behavioral treatments produce improvements in some aspects of
sleep, the most pronounced of which are for sleep latency and
time awake after sleep onset. Relaxation and BF were both found
to be effective in alleviating insomnia. Cognitive forms of
relaxation such as meditation were slightly better than somatic
forms of relaxation such as PMR. Sleep restriction, stimulus
control, and multimodal treatment were the three most effective
treatments in reducing insomnia. No data were presented or
reviewed on the effectiveness of CBT or hypnosis. Improvements
seen at treatment completion were maintained at followups
averaging 6 months in duration. Although these effects are
statistically significant, it is questionable whether the
magnitude of the improvements in sleep onset and total sleep time
are clinically meaningful. It is possible that a patient-by-
patient analysis might show that the effects were clinically
valuable for a special set of patients, as some studies suggest
that patients who are readily hypnotized benefited much more from
certain treatments than other patients did. No data were
available on the effects of these improvements on patient self-
assessment of quality of life.
To adequately evaluate the relative success of different
treatment modalities for insomnia, two major issues need to be
addressed. First, valid objective measures of insomnia are
needed. Some investigators rely on self-reports by patients,
whereas others believe that insomnia must be documented
electrophysiologically. Second, what constitutes a therapeutic
outcome should be determined. Some investigators use time until
sleep onset, number of awakenings, and total sleep time as
outcome measures, whereas others believe that impairment in
daytime functioning is perhaps another important outcome measure.
Both of these issues require resolution so that research in the
field can move forward.
Several cautions must be considered threats to the internal
and external validity of the study results. The following
problems pertain to internal validity: (1) full and adequate
comparability among treatment contrast groups may be absent; (2)
the sample sizes are sometimes small, lessening the ability to
detect differences in efficacy; (3) complete blinding, which
would be ideal, is compromised by patient and clinician awareness
of the treatment; (4) the treatments may not be well described,
and adequate procedures for standardization such as therapy
manuals, therapist training, and reliable competency and
integrity assessments have not always been carried out; and (5) a
potential publication bias, in which authors exclude studies with
small effects and negative results, is of concern in a field
characterized by studies with small numbers of patients.
With regard to the ability to generalize the findings of these
investigations, the following considerations are important:
- The patients participating in these studies are usually not
cognitively impaired. They must be capable not only of
participating in the study treatments but also of fulfilling all
the requirements of participating in the study protocol.
- The therapists must be adequately trained to competently
conduct the therapy.
- The cultural context in which the treatment is conducted may
alter its acceptability and effectiveness.
In summary, this literature offers substantial promise and
suggests a need for prompt translation into programs of health
care delivery. At the same time, the state of the art of the
methodology in the field of behavioral and relaxation
interventions indicates a need for thoughtful interpretation of
these findings. It should be noted that similar criticisms can
be made of many conventional medical procedures.
How Do These Approaches Work?
The mechanism of action of behavioral and relaxation
approaches can be considered at two levels: (1) determining how
the procedure works to reduce cognitive and physiological arousal
and to promote the most appropriate behavioral response and (2)
identifying effects at more basic levels of functional anatomy,
neurotransmitter and other biochemical activity, and circadian
rhythms. The exact biological actions are generally unknown.
There appear to be two pain transmission circuits. Some data
suggest that a spinal cord-thalamic-frontal cortex-anterior
cingulate pathway plays a role in the subjective psychological
and physiological responses to pain, whereas a spinal cord-
thalamic-somatosensory cortex pathway plays a role in pain
sensation. A descending pathway involving the periaqueductal
gray region modulates pain signals (pain modulation circuit).
This system can augment or inhibit pain transmission at the level
of the dorsal spinal cord. Endogenous opioids are particularly
concentrated in this pathway. At the level of the spinal cord,
serotonin and norepinephrine appear to play important roles.
Relaxation techniques as a group generally alter sympathetic
activity as indicated by decreases in oxygen consumption,
respiratory and heart rate, and blood pressure. Increased
electroencephalographic slow wave activity has also been
reported. Although the mechanism for the decrease in sympathetic
activity is unclear, one may infer that decreased arousal (due to
alterations in catecholamines or other neurochemical systems)
plays a key role.
Hypnosis, in part because of its capacity for evoking intense
relaxation, has been reported to reduce several types of pain
(e.g., lower back and burn pain). Hypnosis does not appear to
influence endorphin production, and its role in the production of
catecholamines is not known.
Hypnosis has been hypothesized to block pain from entering
consciousness by activating the frontal-limbic attention system
to inhibit pain impulse transmission from thalamic to cortical
structures. Similarly, other CBT may decrease transmission
through this pathway. Moreover, the overlap in brain regions
involved in pain modulation and anxiety suggests a possible role
for CBT approaches affecting this area of function, although data
are still evolving.
CBT also appears to exert a number of other effects that could
alter pain intensity. Depression and anxiety increase subjective
complaints of pain, and cognitive-behavioral approaches are well
documented for decreasing these affective states. In addition,
these types of techniques may alter expectation, which also plays
a key role in subjective experiences of pain intensity. They
also may augment analgesic responses through behavioral
conditioning. Finally, these techniques help patients enhance
their sense of self control over their illness enabling them to
be less helpless and better able to deal with pain
A cognitive-behavioral model for insomnia elucidates the interaction of insomnia with emotional, cognitive, and physiologic arousal; dysfunctional conditions, such as worry over sleep; maladaptive habits (e.g., excessive
time in bed and daytime napping); and the consequences of
insomnia (e.g., fatigue and impairment in performance of
In the treatment of insomnia, relaxation techniques have been
used to reduce cognitive and physiological arousal and thus
assist the induction of sleep as well as decrease awakenings
Relaxation is also likely to influence decreased activity in
the entire sympathetic system, permitting a more rapid and
effective "deafferentation" at sleep onset at the level of the
thalamus. Relaxation may also enhance parasympathetic activity,
which in turn will further decrease autonomic tone. In addition,
it has been suggested that alterations in cytokine activity
(immune system) may play a role in insomnia or in response to
Cognitive approaches may decrease arousal and dysfunctional
beliefs and thus improve sleep. Behavioral techniques including
sleep restriction and stimulus control can be helpful in reducing
physiologic arousal, reversing poor sleep habits, and shifting
circadian rhythms. These effects appear to involve both cortical
structures and deep nuclei (e.g., locus ceruleus and
Knowing the mechanisms of action would reinforce and expand
use of behavioral and relaxation techniques, but incorporation of
these approaches into the treatment of chronic pain and insomnia
can proceed on the basis of clinical efficacy, as has occurred
with adoption of other practices and products before their mode
of action was completely delineated.
Are There Barriers To the Appropriate Integration of These Approaches Into Health Care?
One barrier to the integration of behavioral and relaxation
techniques in standard medical care has been the emphasis solely
on the biomedical model as the basis of medical education. The
biomedical model defines disease in anatomic and pathophysiologic
terms. Expansion to a biopsychosocial model would increase
emphasis on a patient's experience of disease and balance the
anatomic/physiologic needs of patients with their psychosocial
For example, of six factors identified to correlate with
treatment failures of low back pain, all are psychosocial.
Integration of behavioral and relaxation therapies with
conventional medical procedures is necessary for the successful
treatment of such conditions. Similarly, the importance of a
comprehensive evaluation of a patient is emphasized in the field
of insomnia where failure to identify a condition such as sleep
apnea will result in inappropriate application of a behavioral
therapy. Therapy should be matched to the illness and to the
Integration of psychosocial issues with conventional medical
approaches will necessitate the application of new methodologies
to assess the success or failure of the interventions.
Therefore, additional barriers to integration include lack of
standardization of outcome measures, lack of standardization or
agreement on what constitutes successful outcome, and lack of
consensus on what constitutes appropriate followup.
Methodologies appropriate for the evaluation of drugs may not be
adequate for the evaluation of some psychosocial interventions,
especially those involving patient experience and quality of
life. Psychosocial research studies must maintain the high
quality of those methods that have been painstakingly developed
over the last few decades. Agreement needs to be reached for
standards governing the demonstration of efficacy for
Psychosocial interventions are often time intensive, creating
potential blocks to provider and patient acceptance and
compliance. Participation in BF training typically includes up
to 10-12 sessions of approximately 45 minutes to 1 hour each. In
addition, home practice of these techniques is usually required.
Thus, patient compliance and both patient and provider
willingness to participate in these therapies will have to be
addressed. Physicians will have to be educated on the efficacy
of these techniques. They must also be willing to educate their
patients about the importance and potential benefits of these
interventions and to provide encouragement for the patient
through the training processes.
Insurance companies provide either a financial incentive or
barrier to access of care depending on their willingness to
provide reimbursement. Insurance companies have traditionally
been reluctant to reimburse for some psychosocial interventions
and reimburse others at rates below those for standard medical
care. Psychosocial interventions for pain and insomnia should be
reimbursed as part of comprehensive medical services at rates
comparable to those for other medical care, particularly in view
of data supporting their effectiveness and data detailing the
costs of failed medical and surgical interventions.
The evidence suggests that sleep disorders are significantly
underdiagnosed. The prevalence and possible consequences of
insomnia have begun to be documented. There are substantial
disparities between patient reports of insomnia and the number of
insomnia diagnoses, as well as between the number of
prescriptions written for sleep medications and the number of
recorded diagnoses of insomnia. Data indicate that insomnia is
widespread, but the morbidity and mortality of this condition are
not well understood. Without this information, it remains
difficult for physicians to gauge how aggressive their
intervention should be in the treatment of this disorder. In
addition, the efficacy of the behavioral approaches for treating
this condition has not been adequately disseminated to the
Finally, who should be administering these therapies?
Problems with credentialing and training have yet to be
completely addressed in the field. Although the initial studies
have been done by qualified and highly trained practitioners, the
question remains as to how this will best translate into delivery
of care in the community. Decisions will have to be made about
which practitioners are best qualified and most cost-effective to
provide these psychosocial interventions.
What Are the Significant Issues for Future Research and Applications?
Research efforts on these therapies should include additional
efficacy and effectiveness studies, cost-effectiveness studies,
and efforts to replicate existing studies. Several specific
issues should be addressed:
- Outcome measures should be reliable, valid, and standardized
for behavioral and relaxation interventions research in each area
(chronic pain, insomnia) so that studies can be compared and
- Qualitative research is needed to help determine patients'
experiences with both insomnia and chronic pain and the impact of
- Future research should include examination of
consequences/outcomes of untreated chronic pain and insomnia;
chronic pain and insomnia treated pharmacologically versus with
behavioral and relaxation therapies; and combinations of
pharmacologic and psychosocial treatments for chronic pain and
Mechanism(s) of Action
- Advances in the neurobiological sciences and
psychoneuroimmunology are providing an improved scientific base
for understanding mechanisms of action of behavioral and
relaxation techniques and need to be further investigated.
- Chronic pain and insomnia, as well as behavioral and
relaxation therapies, involve factors such as values, beliefs,
expectations, and behaviors, all of which are strongly shaped by
one's culture. Research is needed to assess cross-cultural
applicability, efficacy, and modifications of psychosocial
- Research studies that examine the effectiveness of
behavioral and relaxation approaches to insomnia and chronic pain
should consider the influence of age, race, gender, religious
belief, and socioeconomic status on treatment effectiveness.
- The most effective timing of the introduction of behavioral
interventions into the course of treatment should be
- Research is needed to optimize the match between specific
behavioral and relaxation techniques and specific patient groups
and treatment settings.
Integration Into Clinical Care and Medical Education
- New and innovative methods of introducing psychosocial
treatments into health care curricula and practice should be
A number of well-defined behavioral and relaxation
interventions are now available, some of which are commonly used
to treat chronic pain and insomnia. Available data support the
effectiveness of these interventions in relieving chronic pain
and in achieving some reduction in insomnia. Data are currently
insufficient to conclude with confidence that one technique is
more effective than another for a given condition. For any given
individual patient, however, one approach may indeed be more
appropriate than another.
Behavioral and relaxation interventions clearly reduce
arousal, and hypnosis reduces pain perception. However, the
exact biological underpinnings of these effects require further
study, as is often the case with medical therapies. The
literature demonstrates treatment effectiveness, although the
state of the art of the methodologies in this field indicates a
need for thoughtful interpretation of the findings along with
prompt translation into programs of health care delivery.
Although specific structural, bureaucratic, financial, and
attitudinal barriers exist to the integration of these
techniques, all are potentially surmountable with education and
additional research, as patients shift from being passive
participants in their treatment to becoming responsible, active
partners in their rehabilitation.
The following references were provided by the speakers listed
above and were neither reviewed nor approved by the panel.
Atkinson JH, Slater MA, Patterson TL, Grant I, Garfin SR.
Prevalence, onset, and risk of psychiatric disorders in men with chronic low back pain: a controlled study. Pain 1991; 45: 111-21.
Beary JF, Benson H.
A simple psychophysiologic technique which elicits the relaxation response. Psychosom Med 1974; 36: 115-20.
Benson H, Beary JF, Carol MP.
The relaxation response. Psychiatry 1974;37:37-46.
The relaxation response. New York: William Morrow, 1975.
Berman BM, Singh BK, Lao L, Singh BB, Ferentz KS, Hartnoll SM.
Physicians' attitudes toward complementary or alternative medicine: a regional survey. JABP 1995; 8 (5):361-6.
Blanchard EB, Appelbaum KA, Guarnieri P, Morrill B, Dentinger MP.
Five year prospective follow-up on the treatment of chronic headache with biofeedback and/or relaxation. Headache 1987; 27: 580-3.
Blanchard EB, Appelbaum KA, Radnitz CL, Morrill B, Michultka D, Kirsch C, Guarnieri P, Hillhouse J, Evans DD, Jaccard J, Barron KD.
A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache. J Consult Clin Psychol 1990; 58: 216-24.
Bogaards MC, ter Kuile MM.
Treatment of recurrent tension headache: a meta-analytic review. Clin J Pain 1994; 10: 174-90.
General considerations of chronic pain in the management of pain (2nd ed.). In: Loeser JD, Chapman CR, Fordyce WE, eds. Philadelphia: Lea & Febiger, 1990. p. 180-2.
Insomnia. J Consult Clin Psychol 1982; 50: 880-95.
Bradley LA, Young LD, Anderson KO, et al.
Effects of psychological therapy on pain behavior of rheumatoid arthritis patients: treatment outcome and six-month followup. Arthritis Rheum 1987; 30: 1105-14.
Carr DB, Jacox AK, Chapman RC, et al.
Acute pain management. Guideline Technical Report, No. 1. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0034. February 1995. p. 107-59.
Caudill M, Schnable R, Zuttermeister P, Benson H, Friedman R.
Decreased clinic utilization by chronic pain patients: response to behavioral medicine intervention.Clin J Pain 1991; 7: 305-10.
Chapman CR, Cox GB.
Anxiety, pain and depression surrounding elective surgery: a multivariate comparison of abdominal surgery patients with kidney donors and recipients. J Psychosom Res 1977; 21: 7-15.
Coleman R, Zarcone V, Redington D, Miles L, Dole K, Perkins W, Gamanian M, More B, Stringer J, Dement W.
Sleep-wake disorders in a family practice clinic. Sleep Research 1980; 9:192.
Brain dynamics and hypnosis: attentional and disattentional processes. Int J Clin Exp Hypn 1994; 42: 204-32.
Crawford HJ, Gruzelier JH.
A midstream view of the neuropsychophysiology of hypnosis: recent research and future directions. In: Fromm E, Nash MR, eds. Contemporary hypnosis research. New York: Guilford, 1992. p. 227-66.
Crawford HJ, Gur RC, Skolnick B, Gur RE, Benson D.
Effects of hypnosis on regional cerebral blood flow during ischemic pain with and without suggested hypnotic analgesia. Int J Psychophysiol 1993;15:181-95.
Cutler RB, Fishbain DA, Rosomoff HL, Abdel-Moty E, Khalil TM, Steele-Rosomoff R.
Does nonsurgical pain center treatment of chronic pain return patients to work? Spine 1994; 19 (6): 643-52.
Daan S, Beersma DGM, Borbely A.
The timing of human sleep: recovery process gated by a circadian pacemaker. Am J Physiol 1984; 246: R161-78.
Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL.
Unconventional medicine in the United States. Prevalence, costs and patterns of use. N Engl J Med 1993.
Eppley KR, Abrams AI, Shear J.
Differential effects of relaxation techniques on trait anxiety: a meta-analysis. J Clin Psychol 1989; 45 (6): 957-74.
Fields HL, Basbaum AI.
Central nervous system mechanisms of pain modulation. In: Wall PD, Melzack R, eds. Textbook of pain (3rd ed.). London: Churchill-Livingstone, 1994. p. 243-57.
Fields HL, Heinricher MM, Mason P.
Neurotransmitters in nociceptive modulatory circuits. Annu Rev Neurosci 1991; 14: 219-45.
Fishbain DA, Rosomoff HL, Goldberg M, Cutler R, Abdel-Moty E, Khalil TM, Steele-Rosomoff R.
The prediction of return to the workplace after multidisciplinary pain center treatment. Clin J Pain 1993; 9: 3-15.
Flor H, Birbaumer N.
Comparison of the efficacy of electromyographic biofeedback, cognitive-behavioral therapy, and conservative medical interventions in the treatment of chronic musculoskeletal pain. J Consult Clin Psychol1993; 61: 653-8.
Gallagher RM, Rauh V, Haugh L, Milhous R, Callas P, Langelier R, Frymoyer J.
Determinants of return to work in low back pain. Pain 1989; 39 (1): 55-68.
Gallagher RM, Woznicki M.
Low back pain rehabilitation. In: Stoudemire A, Fogel BS, eds. Medical psychiatric practice (Vol. 2). APA Press, 1993.
Guideline for the clinical evaluation of analgesic drugs. U.S. Department of Health and Human Services, Public Health Service (FDA) Docket No. 91D-0425, December 1992;1-26.
Hauri PJ, ed.
Case studies in insomnia. York: Plenum Medical Books, 1991.
Heinrich RL, Cohen MJ, Naliboff BD, Collins GA, Bonebakker AD.
Comparing physical and behavior therapy for chronic low back pain on physical abilities, psychological distress, and patients' perceptions. J Behav Med 1985; 8: 61-78.
Herron LD, Turner J.
Patient selection for lumbar laminectomy and discectomy with a revised objective rating system. Clin Orthop 1985;199:145-52.
Hilgard ER, Hilgard JR.
Hypnosis in the relief of pain (rev. ed.). New York: Brunner/Mazel, 1994.
Hoffman JW, Benson H, Arns PA, Stainbrook GL, Landberg L, Young JB, Gill A.
Reduced sympathetic nervous system responsivity associated with the relaxation response. Science 1982; 215: 190-2.
Holroyd KA, Andrasik F, Noble J.
Comparison of EMG biofeedback and a credible pseudotherapy in treating tension headache. J Behav Med 1980; 3: 29-39.
Jacobs G, Benson H, Friedman R.
Home-based central nervous assessment of multifactor behavioral intervention for chronic sleep onset insomnia. Behav Ther 1993;24:159-74.
Jacobs G, Benson H, Friedman R.
Topographic EEG mapping of relaxation response biofeedback and self regulation. In press.
Jacobs GD, Rosenberg PA, Friedman R, Matheson J, Peavy GM, Domar AD, Benson H.
Multifactor behavioral treatment of chronic sleep-onset insomnia using stimulus control and the relaxation response. Behav Modif 1993;17:498-509.
Progressive relaxation. Chicago: University of Chicago Press, 1929.
Jacox AK, Carr DB, Payne R, et al.
Management of cancer pain. Clinical Practice Guideline, No. 9. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 94-00592. March 1994.
Basic mechanisms of sleep-wake states. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia: WB Saunders, 1994. p. 145-62.
Kabat-Zinn J, Lipworth L, Burney R.
The clinical use of mindfulness-meditation for the self- regulation of chronic pain. J Behav Med 1985; 8 (2):163-90.
Behavior as the central outcome in health care. Am Psychol 1990;45:1211-20.
Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robertson D, Roberston C, Martinez S, Nunley J, Beckham JC, Helms M.
Pain coping skills training in the management of osteoarthritic knee pain: a comparative study. Behav Ther 1990; 21: 49-62.
LeBars D, Calvino B, Villanueva L, Cadden S.
Physiological approaches to counter-irritation phenomena. In: Trickelbank MD, Curzon G, eds. Stress induced analgesia. London: John Wiley, 1984. p. 67-101.
Clinical relaxation strategies. New York: Wiley, 1988.
Linton SL, Bradley LA, Jensen I, Spangfort E, Sundell L.
The secondary prevention of low back pain: a controlled study with follow-up. Pain 1989; 36: 197-207.
Loeser JD, Bigos SJ, Fordyce WE, Volinn EP.
Low back pain. In: Bonica JJ, ed. The management of pain. Philadelphia: Lea & Febiger, 1990. p. 1448-83.
Lorig KR, Chastain R, Ung E, Shoor S, Holman HR.
Development and evaluation of a scale to measure the perceived self-efficacy of people with arthritis. Arthritis Rheum 1989B; 32 (1): 37-44.
Lorig KR, Seleznick M, Lubeck D, Ung E, Chastain R, Holman HR.
The beneficial outcomes of the arthritis self-management course are not adequately explained by behavior change. Arthritis Rheum 1989A; 32 (1): 91-5.
Mason PM, Back S, Fields HL.
A confocal laser microscopic study of enkephalin immunoreactive appositions onto physiologically identified neurons in the rostral ventromedial medulla. J Neurosci 1992; 12 (10): 4023-36.
Mayer TG, Gatchel RJ, Mayer H, Kishino N, Mooney V.
A prospective two-year study of functional restoration in industrial low back pain. JAMA 1987; 258: 1763-8.
McCaffery M, Beebe A.
Pain: clinical manual for nursing practice. St. Louis: CV Mosby, 1989.
McClusky HY, Milby JB, Switzer PK, Williams V, Wooten V.
Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia. Am J Psychiatry 1991; 148: 121-6.
McDonald-Haile J, Bradley LA, Bailey MA, Schan CA, Richter JE.
Relaxation training reduces symptom reports and acid exposure in gastroesophageal reflux disease patients. Gastroenterology 1994; 107: 61-9.
Mellinger GD, Balter MB, Uhlenhuth EH.
Insomnia and its treatment: prevalence and correlates. Arch Gen Psychiatry 1985; 42: 225-32.
Human sleep: research and clinical care. New York: Plenum Press, 1987. p. 1-436.
Milby JB, Williams V, Hall JN, Khuder S, McGill T, Wooten V.
Effectiveness of combined triazolam-behavioral therapy for primary insomnia. Am J Psychiatry 1993; 150:1259-60.
Mills WW, Farrow JT.
The Transcendental Meditation technique and acute experimental pain. Psychosom Med 1981; 43 (2): 157-64.
Morin CM, ed.
Insomnia. New York: Guilford Press, 1993.
Morin CM, Culbert JP, Schwartz SM.
Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry 1994; 151(8): 1172-80.
Morin CM, Galore B, Carry T, Kowatch RA.
Patients' acceptance of psychological and pharmacological therapies for insomnia. Sleep 1992; 15: 302-5.
Mountz JM, Bradley LA, Modell JG, Alexander RW, Triana-Alexander M, Aaron LA, Stewart KE, Alarc?n GS, Mountz JD.
Fibromyalgia in women: abnormalities of regional cerebral blood flow in the thalamus and the caudate nucleus and in pain threshold levels. Arthritis Rheum 1995; 38: 926-38.
Murtagh DRR, Greenwood KM.
Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol 1995; 63 (1):79-89.
National Commission on Sleep Disorders Research.
Wake Up America: A National Sleep Alert, Vol. 1. Executive Summary and Executive Report, Report of the National Commission on Sleep Disorders Research, January 1993. Washington DC: 1993, p. 1-76.
National Sleep Foundation.
Gallup poll survey: insomnia in America, 1991.
Neher JO, Borkan JM.
A clinical approach to alternative medicine (editorial). Arch Fam Med (United States) 1994; 3 (10): 859-61.
Onghena P, Van Houdenhove B.
Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 30 placebo-controlled studies. Pain 1992; 49 (2): 205-19.
Medical care utilization and the Transcendental Meditation program. Psychosom Med 1987; 49 (1): 493-507.
Prien R, Robinson D.
Evaluation of hypnotic medications. Clinical Evaluation of Psychotropic Drugs Principles and Guidelines 1994; 22: 579-92.
Schwarzer R, ed.
Self-efficacy: thought control of action. Washington, DC: Hemisphere Publishing, 1992.
Cognitive-behavioral relaxation training. New York: Springer, 1990.
Spielman AJ, Saskin P, Thorpy MJ.
Treatment of chronic insomnia by restriction of time in bed. Sleep 1987; 10: 45-56.
Behavioral therapy for insomnia. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia: WB Saunders, 1994. p. 535-41.
Sleep oscillations and their blockage by activating systems. J Psychiatry Neurosci 1994; 19: 354-8.
Pain and "hassles" in the United States: findings of the Nuprin Report. Pain 1986; 27: 69-80.
Survey of pain in the United States: The Nuprin Report. Clin J Pain 1986; 2: 49-53.
Economic effects of insomnia. Clin Ther 1994; 16(5).
Integrating medical and psychological treatments for cancer pain. In: Chapman CR, Foley KM, eds. Current and emerging issues in cancer pain: research and practice. New York: Raven Press, 1995.
Magnocellular nuclei of the basal forebrain: substrates of sleep and arousal regulation. Sleep 1995;18: 478-500.
Customizing treatment for chronic pain patients. Who, what, and why. Clin J Pain 1990; 6: 255-70.
Turk DC, Marcus DA.
Assessment of chronic pain patients. Sem Neurol 1994; 14: 206-12.
Turk DC, Melzack R.
Handbook of pain assessment. New York: Guilford Press, 1992.
Turk DC, Rudy TE.
Toward an empirically derived taxonomy of chronic pain patients: integration of psychological assessment data. J Consult Clin Psychol 1988; 56:233-8.
Turner JA, Clancy S.
Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain. J Consult Clin Psychol 1984; 56: 261-6.
Wallace RK, Benson H, Wilson AF.
A wakeful hypometabolic state. Am J Physiol 1971; 221: 795-9.