Center For Cognitive Therapy

Bio-Behavioral Management of Chronic Pain

Chronic pain is comprised of many factors, some of which may be behavioral in nature (e.g. what we think, feel, and do). Stress is perhaps one of the most common behavioral factors that interacts with physical factors in the perpetuation of pain. When a person is stressed, the reaction is physical as well as behavioral. Furthermore, the experience of pain is stressful so every chronic pain patient experiences stress to some degree.

Bio-behavioral pain control is a six-session treatment designed to teach control over pain by controlling physical reactions to stress and pain through relaxation, stress reduction, and chronic pain management techniques. These skills can be applied to a wide range of pain problems such as low back pain, cancer pain, arthritic pain, temporomandibular dysfunction (TMJ), neck pain, and headaches. Bio-behavioral pain control maximizes the learning of effective pain control without medication.


There are perhaps as many different types of stress as there are snow-flakes. Negative types of stress may come in the form of anger, anxiety about impending deadlines, or an over committed lifestyle. Stress can also occur in the context of a positive experience such as a job promotion or getting married. Finally, stress can occur in seemingly neutral situations (e.g. while absorbed in a task) without actually feeling stress while responding physically in ways that can lead to pain. Stress can occur without our awareness because the emotional experience of stress is very relative and depends on a “frame of reference”. For example, a person may respond to situations in a consistently “stressful” way, but because this has always been the way they respond, it feels “normal”. Therefore, stress management skills can control pain even in those individuals who do not describe themselves as feeling stressed.


Although stress can occur in so many different forms, our body tends to respond in characteristic ways that can cause, aggravate, and/or maintain pain. Physical reactions to stress can interact with chronic pain (e.g. low back, TMJ, headache, neck etc…) in ways that are unique to that particular disorder. For example:

LOW BACK PAIN can often be aggravated by stress accompanying increases in muscle activity in the lower back. Furthermore, as with any pain, stress and mood can influence how pain information is processed and perceived. Also, with low back and arthritic pain, physical limitations often lead to bad moods, which influence the quality of life.

TEMPOROMANDIBULAR DYSFUNCTION (TMD) patients have certain physical problems with their jaw and related muscles. During stress, which most people experience to various degrees, neck and jaw muscles become tight producing a mechanical aggravation of the painful area leading to increased pain. TMD patients often experience facial pain upon awakening which is highly correlated with grinding or clenching teeth during sleep.

HEADACHE patients have physical predispositions that make them more vulnerable to normal stress levels. Physical responses to stress include increased muscle activity in the neck, disturbance of blood flow to the head, and inflammation of muscles in the neck and head. These responses often lead to headaches in the predisposed individual.

NECK PAIN as well as facial and head pain can be due to overactive muscles leading to inflammation known as “myofascial” pain. In response to this increased muscle activity further inflammation occurs. This creates a vicious circle where pain is maintained and increased.

IRRITABLE BOWEL SYNDROME/ GI DISTRESS: The gastro-intestinal tract is a system designed to work at certain times and be relatively quiet at others. The central nervous system, which is one of the physical bases of emotion, has many inputs to this system. During stress, some individuals respond physically by increasing secretions and other activities within this system. Over time and repeated reactions, the system begins to malfunction, resulting in symptoms of distress that aggravate and maintain irritable bowel syndrome or GI distress.

PAIN/STRESS VICIOUS CIRCLE: The most common source of stress for a person who has pain is pain. Many of the above reactions occur while feeling pain, which serves to maintain or increase pain in an upwardly spiraling cycle.


The previous examples illustrate the importance of managing the body’s response to stress and pain. Therefore, major emphasis is placed on a comprehensive approach to stress management as it relates to pain management. Also, chronic pain can have a negative impact on many aspects of everyday living and can affect overall quality of life. These factors are assessed and addressed.


  • Progressive muscle relaxation training
  • Deep diaphragmatic breathing
  • Imagery
  • Cue-controlled rapid relaxation
  • Cognitive therapy for stressful situations
  • Guided mastery of stress/pain-management application.
  • Biofeedback for physiological self-regulation of pain.

All of these skills are designed to teach patients control over behavioral and physical reactions that play a role in pain during everyday life situations. Scientific research has shown that these skills are usually very helpful in reducing pain.

Each person receives a step-by-step instruction manual that covers the material presented in sessions and a series of 3 cassette tapes for Bio-behavioral Pain Control.