Mindfulness as Effective as CBT in Pain Catastrophizing

Laird Harrison

May 21, 2015

PALM SPRINGS, California — Mindfulness-based stress reduction (MBSR) may do as much as cognitive-behavioral therapy (CBT) to calm the catastrophizing thought patterns of people with chronic back pain, researchers say.

Overall the two approaches showed strikingly similar effects, first author Judith Turner, PhD, told Medscape Medical News. "It would be fair to conclude that both treatments are fairly effective compared to usual care," she said.

Dr Turner, a professor of psychiatry at the University of Washington in Seattle, presented these findings here at the American Pain Society (APS) 34th Annual Scientific Meeting.

Previous research has shown that both MBSR and CBT can reduce chronic pain. However, CBT requires administration by a doctorate-level psychologist, while MBSR can be taught by someone who has taken a shorter training course.

And the two come from different traditions. MBSR derives from Buddhism, while CBT derives from Western schools of psychology, with roots in ancient Greek Stoicism.

Trying to understand how MBSR works, researchers showed that it increases mindfulness — an awareness of pain without judgment — and that it might also increase acceptance of pain.

CBT researchers have shown that it decreases catastrophizing, the tendency to exaggerate the consequences of pain. They've also shown that it increases self-efficacy, the belief that the individual can make a positive change.

"We wanted to look at how much overlap there is in what were traditionally thought to be very different constructs," Dr Turner said.

So she and her colleagues recruited patients from Group Health, a large nonprofit organization of healthcare providers in Washington State.

They screened 1977 patients with chronic pain and enrolled 342 in the study, of whom 290 completed assessments. The patients' mean age was 49 years. Sixth-six percent were female and 79% had had back pain for at least a year.

The researchers randomly assigned 95 patients to the CBT group, 91 to the MBSR group and 105 to usual care. The CBT patients underwent eight weekly 2-hour group sessions with instruction and practice in cognitive and behavioral skills for managing pain and associated problems.

The MBSR patients attended eight weekly classes and a 6-hour retreat with instruction and practice in mindfulness, meditation, and yoga. The usual care patients received whatever treatment their providers offered. The researchers then administered a variety of questionnaires to the patients in all three groups.

  • The Pain Catastrophizing Scale assesses rumination, helplessness, and magnification.

  • The Pain Self-Efficacy Questionnaire assesses confidence in the ability to cope with pain and engage in activities despite pain.

  • The Chronic Pain Acceptance Questionnaire is divided into two parts. Activity Engagement assesses pursuit of life activities in a normal manner even when the patient is in pain, and Pain Willingness assesses recognition that strategies for avoiding or controlling pain are ineffective.

  • The Five Facet Mindfulness Questionnaire form includes four subscales. The Observing subscale assesses ability to notice internal and external experiences. The Acting with Awareness subscale assesses the ability to attend to present moment activities. The Nonreactivity subscale assesses the extent to which a person allows thoughts and feelings to arise and pass without attachment or aversion. The Nonjudging subscale assesses a nonevaluative stance toward thoughts, emotions, and feelings.

The researchers administered the same questionnaires again after 8 weeks, when the therapy sessions had ended.

After adjustment for age and sex and for baseline scores on pain intensity, disability, and process measure, the researchers found that all the groups improved somewhat.

But the CBT group improved significantly more than the usual care group on self-efficacy, observing, and nonjudging. The MBSR group improved significantly more than the usual care group on catastrophizing, acceptance, pain willingness, self-efficacy, and nonjudging.

Compared with the CBT group, the MBSR group also had significantly greater improvements in catastrophizing and nonjudging.

However, when they compared only the 61 patients with CBT and 55 patients with MBSR who completed at least 6 of the 8 sessions, the differences between these two groups changed.

In this analysis, two facets of mindfulness — observing and nonreactivity — increased significantly more in CBT than in MBSR. One facet of mindfulness — nonjudging — increased significantly more in the MBSR than in the CBT group.

"We did not expect the CBT people to become more mindful," said Dr Turner. "That was a surprise to us."

But the analysis didn't necessarily show that either of the active treatments was more powerful than the other. "Although there were these differences, they were generally modest in size," said Dr Turner.

Still, she said, the finding could be useful because MBSR doesn't require a doctorate to administer. "So there is probably more access to MBSR than to CBT."

The researchers are now completing a further analysis to see how changes in the patients' scores on pain and depression changed among the three groups. "If it turns out that they are both effective in outcomes, this would give a boost to MBSR," she said.

The study adds a unique perspective to the literature comparing these approaches, said Matthew Herbert, PhD, a psychologist at the University of Alabama in Birmingham. "There's a big ongoing battle between the CBT approach and more of a third-wave acceptance approach," he told Medscape Medical News.

Trials like this one can help define the similarities and differences, he said. "Hopefully you can see that people are more suited for one intervention versus the other," he said.

This study was funded by the National Center for Complementary and Alternative Medicine (since renamed the National Center for Complementary and Integrative Health). Neither Dr Turner nor Dr Herbert has disclosed any relevant financial relationships.

American Pain Society (APS) 34th Annual Scientific Meeting. Abstract 481. Presented May 14, 2015.

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