4 - (SYM 53) Pain Reprocessing Therapy: A Novel Exposure-based Treatment Enabling Recovery from Chronic Pain

Chronic pain is a leading cause of disability and disproportionately affects people with poor social determinants of health. Effective treatments are lacking. Converging research from the fields of medicine, neuroscience, and psychology demonstrates that many cases of chronic pain are driven by sensitization in brain pathways and fear-avoidance learning processes, not by injuries or tissue damage. In this subtype, known as nociplastic or primary chronic pain, chronic pain can be conceptualized as a “false alarm” generated by the nervous system which is not indicative of injury or tissue damage—a conceptualization that is similar to panic disorder and motivates exposure-based treatments. Yet, many current leading psychological treatments (e.g., CBT-Chronic Pain) do not treat chronic pain from this perspective. Instead, they promote fear by reinforcing the idea that pain may indicate tissue damage and prescribe avoidance behaviors for homework (e.g., direct patients to reduce activity when pain increases). Efficacy of these psychological treatments is limited, typically resulting in a ~1.5 point decrease on a 10 point pain scale from pre-to-post-treatment. Aligned with this year's conference theme of innovation, I present here efficacy and mechanistic findings for a novel psychological treatment, Pain Reprocessing Therapy (PRT). PRT is centered on reducing fear and avoidance of pain via interoceptive and behavioral exposures and cognitive restructuring focused on changing patients’ understanding of the underlying causes of their pain. In a recently published clinical trial of chronic back pain (N = 151 adults), 66% of patients randomized to PRT were pain-free or nearly so, as compared to fewer than 20% of placebo and usual care controls (Ashar et al., 2022 JAMA Psychiatry). Pain reductions were largely maintained for 1-year post-treatment. At the neurobiological level, longitudinal fMRI revealed that PRT vs. control was associated with changes in prefrontal and somatosensory cortical function. At the psychological level, effects of PRT vs. control on pain were mediated by reduced fear and avoidance and by changes in pain attributions—a novel mechanism measured with natural language tools capturing how patients spontaneously think about the underlying causes of their pain. Overall, these findings upend traditional paradigms viewing chronic pain as a condition that can only be managed, showing that exposure-based psychological treatments can resolve many cases of chronic pain.