Cognitive Behavioral Therapy: Effective Endometriosis Pain Relief?

Cognitive Behavioral Therapy: Effective Endometriosis Pain Relief?

For decades, endometriosis pain confronted Karma Reznor at every turn.

Two excision surgeries didn't fend off the killer cramps that haunted her since age nine. Complementary medicine and medical treatments didn' t work, either.

“I had tried every painkiller and medication they threw at me and had very little relief. I had literally tried everything: injections, acupuncture, pills, physical therapy, a TENs unit, and even diets,” Reznor tells The Blossom.

Feeling hopeless, Reznor, 36, decided to see a naturopathic doctor, and soon learned that the naturopath was also a psychologist. It was then that she decided to give Cognitive Behavioral Therapy, or CBT, a try.

“CBT was my last hope.”

Her doctor prescribed her self-care homework assignments like positive mantras and meditation. Reznor also learned a "rest" word that she says helps her to process pain. “I’ve worked on replacing negative thoughts with positive ones. Constantly telling myself, I’m in pain and focusing on the pain wasn't getting me anywhere. Now, I replace that thought by acknowledging that it’s a temporary thought. I tell myself, ‘Stop. I am healthy. I'm in control of my life now.’”

Reznor says that shifting her focus away from pain and focusing on other thoughts like a positive motto, has made a difference.

Christine Sieberg, Ph.D., an Assistant Professor of Psychiatry at Harvard Medical School, says endometriosis pain is real, and so too is the power of the mind to tamp it down to a more tolerable level. 

“Pain is a complex biological, psychological, and social experience. There’s a lot of overlap between pain, depression, and anxiety,” says Sieberg, a pain psychologist with expertise in CBT and endometriosis.

She says some endo women can become unresponsive to standard medical and surgical therapies due to excessive pain sensitivity, known as central sensitization. “Activation of the stress-response network has been found to lower pain thresholds in both animals and humans, and high levels of anxiety are consistently related to higher pain sensitivity.”

“We only have one nervous system, and it has to process a lot of information.” 

‘Addressing fear of pain’

Although few studies have been done on the effectiveness of CBT in patients with endometriosis, the technique, which was born in the 1960’s, has been used in cancer patients as well as those with chronic pain conditions like low back pain, headaches, and fibromyalgia.  Endo warrior or not, Sieberg says anyone seeking pain relief can benefit from CBT sessions. 

“CBT includes a combination of cognitive and behavioral techniques that involve a variety of cognitive skills like positive self-talk and behavioral strategies like relaxation,” says Sieberg.

CBT also involves setting goals for treatment and tracking symptoms over time, usually with a diary. During the sessions, therapists and patients work to change negative thoughts and behaviors through problem-solving and developing learning experiences to counter them.

“Typically, 8 to 12 weekly sessions with adherence to homework assignments is adequate for most women. However, if there is extreme impairment in functioning and disruption of the patient’s mood, more sessions may be needed,” says Sieberg, who adds that patients who want to try the technique can ask ask their primary care doctor for a referral or can search for a specialist via abct.org, which is the Association for Behavioral and Cognitive Therapies.

A large part of CBT is addressing the fear of pain by having the patient engage in activities perceived as potentially harmful or anxiety-provoking during the therapy session in a controlled manner. “We expose patients to the feared event or stimulus to desensitize them. We try to do this in real time, in a session. We are as creative as possible, but sometimes we create the scenario by discussing it or having the patient imagine it,” says Sieberg.

For example, a patient avoiding sexual intimacy due to fear of endo-related pain may be asked to create a fear hierarchy, or rate her fear on a scale from 1 to 10. Because an intimate setting cannot be recreated in a therapy session, Sieberg may do an imaginal exercise, in which the patient thinks about the steps involved in sexual intimacy.

Homework might involve a woman having various exposures with her partner in the home setting. For some women, low-level exposure may be talking to her partner about her fears of sexual intimacy and perhaps gradually increasing physical contact over time, she explains.

“The homework is always tailored to the specific needs of the patient. Goals include directing attention away from pain, enhancing a sense of control over pain, and diminishing negative thoughts and feelings related to pain.” 

Another goal of CBT is for patients to practice the therapeutic techniques on their own. “The patient should have a good toolkit to utilize for the prevention and treatment of pain flares,” adds Sieberg.

Advice that Reznor says she’s made a part of her endo-pain strategy. “Now, I take a focused breath and count before reacting negatively to a situation. My rest word is ‘free’ as in, I am free from symptoms and pain. Repeating this word and reframing my thoughts helps me change my perspective. After a bit, I believe my thoughts and find relief.”