What Works? Processes of Change in a Transdiagnostic Exposure Treatment for Patients With Chronic Pain and Emotional Problems

Abstract

Objectives:We recently developed a transdiagnostic exposure treatment ("the hybrid treatment") for chronic pain patients with concurrent emotional difficulties. This paper investigates the hypothesized treatment processes, specifically: a) if changes on pain-related dysregulation (catastrophizing, fear-avoidance and non-acceptance of pain) and general emotion dysregulation (difficulties to regulate a broad spectrum of emotional responses) mediate effects on outcomes; and b) if mediation is more pronounced for patients who score higher on these processes pre-treatment. Methods:Structural equation modeling for longitudinal data using the full intention-to-treat sample was used to test whether proposed variables mediated the effect of the hybrid treatment (n=58) compared to a guided internet delivered pain management treatment based on cognitive-behavioral principles (iCBT; n=57) on pain interference and depressive symptoms at 9-months follow up. To make full use of the multiple process-measures collected in the trial, we modeled mediators as two continuous latent variables: pain-related dysregulation and general emotion dysregulation. Results:Reduced pain-related dysregulation mediated the effects of treatment on both outcomes, whereas reduced general emotion dysregulation mediated the effects on depressive symptoms only. In the hybrid treatment, the mediated effect was more pronounced for participants who scored higher on pain-related dysregulation pre-treatment relative to those who scored lower. Discussion:Our findings provide initial support for the transdiagnostic theoretical underpinnings of the hybrid treatment model. Using a hybrid treatment approach that centers on teaching patients emotion regulation skills before commencing broad exposure, successfully influenced both pain-related dysregulation and general emotion dysregulation, which in turn was associated with better treatment outcomes. It appears central to address these processes in pain patients with comorbid emotional problems, especially among patients scoring high on measures regarding catastrophizing, fear-avoidance and non-acceptance of pain.

How do psychologically based interventions for chronic musculoskeletal pain work? A systematic review and meta-analysis of specific moderators and mediators of treatment

“…Leeuw et al (2008) showed that pain-related fear and catastrophizing mediated the effects of exposure in vivo on disability compared to graded activity, accounting for 75% of the total effect. Sodermark et al (2020) reported that a latent variable consisted of pain-related fear, catastrophizing and acceptance mediated the effects of a hybrid CBT intervention (including techniques addressing comorbid depression) on disability compared to traditional CBT. Lastly, Wetherell et al (2011) compared the mediated effects of pain acceptance and self-efficacy on disability between CBT and ACT and reported no mediated effects for any of them.…”

“…After the first screening of titles and abstracts, 152 publications were retrieved for full-text screening. Finally, 37 studies were included with a total of 28 mediation analyses (n = 4652) (Cederberg, Cernvall, Dahl, von Essen, & Ljungman, 2016;Chalder, Goldsmith, White, Sharpe, & Pickles, 2015;Coronado et al, 2020;Durá-Ferrandis, Ferrando-García, Galdón-Garrido, & Andreu-Vaillo, 2017;Fordham, Ji, Hansen, Lall, & Lamb, 2017;Garland et al, 2019;Hedman-Lagerlof et al, 2019;Leeuw et al, 2008;Lin, Klatt, McCracken, & Baumeister, 2018;Luciano et al, 2014;Mansell, Hill, Main, Von Korff, & Van Der Windt, 2017;Mansell, Hill, Main, Vowles, & van der Windt, 2016;Mansell, Storheim, Løchting, Werner, & Grotle, 2017;Molinari et al, 2019;O'Neill, O'Sullivan, O'Sullivan, Purtill, & O'Keeffe, 2020;Pérez-Aranda et al, 2019;Simister et al, 2018;Smeets, Vlaeyen, Kester, & Knottnerus, 2006;Sodermark et al, 2020;Spinhoven et al, 2004;Taylor et al, 2018;Trompetter, Bohlmeijer, Fox, & Schreurs, 2015;Turner, Holtzman, & Mancl, 2007;van Koulil et al, 2011;Wetherell et al, 2011;Wiborg, Knoop, Frank, & Bleijenberg, 2012;Wicksell et al, 2013;Wicksell, Olsson, & Hayes, 2010) and 11 moderation analyses (n = 1925) (Broderick et al, 2016;Buckelew et al, 1996;Day et al, 2019;Flink, Boersma, & Linton, 2010;Lawford et al, 2018;...…”

“…In most of the cases, these can be considered non-specific because despite CBT and ACT have been shown to be effective in managing other psychological disorders (e.g., major depressive disorder), specific techniques focusing on reducing anxiety and depression have rarely been integrated within the pain management intervention (Goesling, Clauw, & Hassett, 2013;Linton & Bergbom, 2011). Among all included studies, only one intentionally targeted these constructs during treatment through specific techniques (Sodermark et al, 2020).…”

All good things come in threes: A systematic review and Delphi study on the advances and challenges of ambulatory assessments, network analyses, and single-case experimental designs.

“…An integrative perspective of the three methods together might offer even more methodological potential. The far-reaching AA expertise concerning the technical implementation and practicalities of diverse sampling schemes (including multimodal assessments of passive data) could serve as a basis for improving other methodological approaches (e.g., Myin-Germeys et al, 2018; Södermark et al, 2020; Wichers et al, 2019). The NA approach makes a further contribution by revealing mutually reinforcing dynamics of the critical variables assessed (Fried & Cramer, 2017).…”