Cognitive-Based Pain Self-Management Strategies in Serious Illness

  • Laura Meyer-Junco PharmD

Download PDF

Background: Although pain experiences vary widely, all patients with pain must manage its impact on their lives and emotions (1,2). Pain self-management (SM) skills have been described in the published literature as an adjuvant way (often in conjunction with analgesics) to help patients understand and even modify the emotional components of living with pain (2-6). Many of these SM skills are based in cognitive behavioral therapy (CBT) (1). This Fast Fact will review cognitive-based pain SM strategies for patients with serious illness that have supporting evidence and can be employed by generalist clinicians.

Teaching the brain-pain connection: Adoption of SM concepts by patients and caregivers begins with understanding the role of the brain in pain (1,2,7). Cognitive factors such as pain expectations, meaning of pain, and beliefs about the cause of pain can deeply influence pain processing as can emotional factors such as fear, anxiety, and sadness (8-9). To broaden patients’ understanding of pain beyond just the physical dimension of tissue damage, for example, a more multi-dimensional, biopsychosocial explanation for chronic pain is employed (1,2,7,10-12). This biopsychosocial explanation for pain is a key component of pain neuroscience education (PNE). PNE incorporates analogies and metaphors to help patients understand how their thoughts, behaviors, and emotions affect their pain perception (7-10,12). PNE has been associated with improved patient reported pain scores, improved mobility, and a reduction in healthcare utilization for patients with chronic musculoskeletal (MSK) pain, fibromyalgia, and chronic pain among cancer survivors (13-17). It is not yet known if PNE can be opioid sparing. Below are three common PNE analogies described in the published literature.  No one analogy has been shown to be superior to another; a combination is often used (11).

  • The Gate and Neuromatrix Analogy: Derived from the gate-control theory of pain, clinicians describe a figurative “gate” in the spinal cord that can be opened or shut to modulate the amount of sensory input that reaches the brain (1,2,18). Negative thoughts, poor mood, lack of sleep, and stress are described as factors that open the “gate” and thereby allow noxious stimuli greater access to the brain. While the gate analogy primarily explains central neural mechanisms for pain, clinicians can also discuss the brain’s larger network of neurons — “the neuromatrix” – that processes body sensations, thoughts, and emotions simultaneously (2, 18).
  • The Alarm System or Fire Alarm Analogy: In the analogy of an alarm system, clinicians can describe how the brain acts as a figurative command center, evaluating all sensory inputs it receives from the body in tandem with all the information previously stored inside it (memories, learned responses, thoughts and emotions). From this information, the brain interprets whether the body is in danger. Negative thoughts skew the brain’s interpretation of the inputs toward danger, causing the brain to “sound the alarm” and ramp up the amount of pain experienced.  Over time (as in chronic pain), this alarm system can become too sensitive, going off with less sensory input (7,10). An analogy of a malfunctioning fire alarm can be used to describe this central sensitization (e.g., instead of the alarm going off to a house fire, it goes off to a single birthday candle) (19).
  • Telephone Cable or Radio Station Analogy: To emphasize the role of distraction in reducing pain intensity, clinicians can describe how nerves, like telephone cables, carry many types of signals but are limited on the number they can carry at once (20). For this reason, patients can understand how rubbing your elbow after hitting your funny bone may reduce the amount of pain felt. Alternatively, a clinician can describe that like a radio has many stations, our mind has many thoughts. Just as only one radio station may be played at a time, the mind only focuses well on one thought at a time (2, 21).

Retraining the brain: It is vital that clinicians always validate their patient’s pain experience, its severity, and the way it impacts daily functioning. PNE does not mean to imply that a patient’s pain experience is self-chosen or easily avoided. However, a core principle of PNE and pain SM is that patients can develop skills to reduce the emotional intensity associated with pain. Studies suggest that cognitive restructuring techniques and relaxation activities such as the ones outlined below reduce pain, improve coping skills, and reduce pain catastrophizing in patients with chronic MSK pain, fibromyalgia, rheumatoid arthritis, sickle cell disease, chronic headache, and cancer pain (4-6,22-24).

Recent literature also suggests these techniques can be implemented in routine clinical settings without extensive specialized training (5,25). Of note, these strategies are less likely to be effective for an acute pain crisis (e.g., fracture, sickle cell crisis).

  • Encourage patients to identify negative self-talk brought on by pain and replace these thoughts with more positive thoughts or affirmations such as “I am more than my pain,” or “I am loved” (1,2).
  • Educate patients on relaxation techniques such as diaphragmatic breathing (or belly breathing), guided imagery, or body scan exercises (1,2).
  • Encourage patients to pursue pleasant activities (even when they are experiencing ongoing pain) to distract the mind, help “close the gate” on their pain response, and quite the “danger alarm” (2).
  • Promote good sleep hygiene as another means to “close the gate” on pain (2).

Summary: Early studies indicate that PNE-based SM skills are a promising, low-risk way to improve patient’s sense of emotional control over chronic pain. For more information on PNE and cognitive pain SM, see references 1,2,7, and 10 below.


  1. Thorn BE. Cognitive Therapy for Chronic Pain: A Step-by-Step Guide, 2nd edition. New York, NY: The Guilford Press, 2017.
  2. Lefort S, Lorig K, Sobel D, et al, eds: Living a Healthy Life with Chronic Pain: Getting Your Life Back. 2nd edition. CO: Bull Publishing Company, 2021.
  3. Lovell M, Luckett T, Boyle F, et al. Pain education, coaching, and self-management for cancer pain. J Clin Oncol 2014; 32 (16): 1712-1720.
  4. McCorkle R, Ercolano E, Lazenby M, et al. Self-management: enabling and empowering patients living with cancer as a chronic illness. CA Cancer J Clin 2011; 61: 50-62.
  5. Daniels S. Cognitive behavior therapy for patients with cancer. J Adv Pract Oncol 2015; 6(1): 54-56.
  6. Lefort S,Gray-Donald K, Rowat K, Jeans M. Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain. Pain 1998; 74: 297-3
  7. Butler D, Moseley L, eds: Explain Pain, 2nd edition. Adelaide, Australia: Noigroup Publications, 2013.
  8. Villemure C, Bushnell C. Cognitive modulation of pain: how do attention and emotion influence pain processing? Pain 2002; 95:195–199.
  9. Bushnell MC, Ceko M, Low L. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci 2013; 14(7): 502–511.
  10. Louw A,Puentedura E. Therapeutic Neuroscience Education: Teaching Patients About Pain. A Guide for Clinicians. Minneapolis, MN: International Spine and Pain Institute, 2013.
  11. Louw  A, Puentedura EJ, Diener I, Zimney KJ, Cox T. Pain neuroscience education: which pain neuroscience education metaphor worked best? South African Journal of Physiotherapy 2019;  75(1), a1329. https://doi.org/ 10.4102/sajp.v75i1.1329
  12. Nijs J, Amarins J,Wijma A, Leysena L, Pasa R, Ward W, Hoelen W, Ickmans K, van Wilgen CP. Explaining pain following cancer: a practical guide for clinicians. Braz J Phys Ther 2019; 23(5): 367-377. .
  13. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation 2011; 92: 2041–2056.
  14. Louw A, Zimney K, Puentedura E,Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature, Physiotherapy Theory and Practice 2016; 32:5, 332-355, DOI:10.1080/09593985.2016.1194646
  15. Pas R, Leysen L, De Goeij W,  Vossebeld L, Van Wilgen P, De Groef A, De Kooning M. Pain neuroscience education in cancer survivors with persistent pain: a pilot study. Journal of Bodywork & Movement Therapies 2020; 24: 239-244.
  16. Van Oosterwijck J, Meeus M, Paul L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized Clin J Pain. 2013;29(10):873-882.
  17. Gallagher L, Mcauley J,  Moseley  GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. The Clinical Journal of Pain 2013; 29(1), 20–25. https://doi. org/10.1097/AJP.0b013e3182465cf7
  18. Melzack R. From gate to the neuromatrix. Pain 1999 Aug; Suppl 6: S121-S126.
  19. Schneider E, DiLillo R, Hullstrung G. Retrain Pain Foundation. Understand Pain. Available at: www.retrainpain.org Accessed May 15, 2021.
  20. Whitten CE, Donovan M, Cristobal K.  Treating chronic pain: new knowledge, more choices. The Permanente Journal 2005; 9 (4): 9-18
  21. Lorig K, Gonzalez V, Laurent D, et al. The Virtual Chronic Pain Self-Management Workshop. An Evidence-Based Self-Management Program Originally Developed at McGill University and Memorial University of Newfoundland in collaboration with Stanford University *(Leader’s Manual). Aptos, CA: Self-Management Resource Center, 2022.
  22. Williams AC de C, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD007407. DOI: 10.1002/14651858.CD007407.pub4
  23. Gil K, Wilson J, Edens J, Webster D, Abrams M, Orringer E, et al. Effects of cognitive coping skills training on coping strategies and experimental pain sensitivity in African Americans adults with sickle cell disease. Health Psychology 1996; 15(1): 3-10.
  24. James L, Thorn B, Williams DA. Goal specification in cognitive-behavioral therapy for chronic headache pain Behavior Therapy 1993; 24(2): 305-320.
  25. Murphy, J. L., Cordova, M. J., & Dedert, E. A. (2022). Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program. Psychological Services, 19(1), 95-102. doi:https://doi.org/10.1037/ser0000506

Conflicts of Interest: None
Author Affiliations: University of Illinois at Chicago College of Pharmacy, Rockford, IL; Mercyhealth Hospice and Palliative Care, Rockford, IL: St. Croix Hospice, Rockford, IL
Version History: First electronically published in March 2023; originally edited by Lara India MD