PAIN+ CPN

Doctor, I have chronic pain with anxiety and/or depression. Will it help me to try transdiagnostic emotion-focused exposure treatment?


Patients with chronic pain may benefit from treatments that address emotional problems such as anxiety and depression. Emotion-focused exposure treatments may provide similar benefits to other established treatments such as cognitive behavioural therapy. This new treatment may be an option for some people with chronic pain.   

What is the evidence?


Researchers looked at patients with chronic musculoskeletal pain with comorbid anxiety and/or depression and compared transdiagnostic emotion-focused exposure treatment with internet-delivered cognitive behavioural therapy (CBT) in these patients. They measured depression, anxiety, pain, and pain interference after treatment and 9 months later. They found that:

  • There was no difference in pain or anxiety between people who received emotion-focused exposure treatment and those who received internet-delivered CBT at any time
  • Patients in the emotion-focused exposure treatment group had less depression at nine months after treatment
  • Patients in the emotion-focused exposure treatment group had less pain interference in participation of activities of daily life than those in the CBT group after treatment and at nine months after treatment
  • Participants felt that emotion-focused exposure treatment was more acceptable and were more satisfied with their treatment compared with internet-delivered CBT
  • This study did not include a control group where people received usual care, or did not receive an emotion-focused treatment

What kind of study was this?



This was a randomized controlled trial (RCT). In an RCT, patients are randomly assigned to receive the treatment under study or a comparator treatment.

Who participated in the study? This study included 115 people in Sweden who had chronic musculoskeletal pain (for >6 months duration), functional problems in their daily life due to pain, and emotional problems (anxiety or depression).

How was the study done? The study compared transdiagnostic emotion-focused exposure treatment with internet-delivered cognitive behavioural therapy.

Transdiagnostic emotion-focused exposure treatment

vs

Internet-delivered cognitive behavioural therapy


This treatment approach aims to teach patients emotion-regulation skills in a context of nonjudgmental acceptance and desired goal pursuit. There are five stages of treatment. (1) Patients build a working relationship with their provider, soothe their distress, and develop goals (2) Patients develop skills to prepare for exposure and improve the regulation of pain and emotion in their regular life (3) Patients receive exposure for emotions and movements (4) training and applying skills (5) Maintaining and refining the skills.

Patients had sessions once per week for 10-15 weeks with clinical psychologists. Content of each individual session was tailored to the patient’s needs.


Patients received 8 treatment modules through an internet platform with educational texts, pictures, case examples, audio files, and 2-3 homework assignments per module. Module themes included coping with pain through exercise, behavioural strategies, and cognitive strategies, mindfulness, stress and pain, sleep and pain, and maintenance. Patients were guided through modules by clinical psychologists, with whom they communicated through the chat function of the platform on an as-needed basis. Treatments lasted approximately 12 weeks.


Why was this research done?


Chronic pain and emotional problems such as anxiety and depression frequently coexist. The presence of anxiety or depression in chronic pain patients may contribute to worse long-term functioning, including being less likely to work. There has been interest in treatments for chronic pain that also address anxiety and depression.

“Transdiagnostic” refers to psychological mechanisms that may maintain and exacerbate both pain and emotional problems. This treatment combines exposure therapy, which exposes people to something they fear in order to break patterns of fear and avoidance, with emotion-regulation approaches informed by Dialectical Behaviour Therapy.

This approach was tested in a small group of patients with low back pain and showed encouraging results. The authors wanted to test this hybrid approach in a randomized controlled trial with an active comparator. The authors chose internet-delivered cognitive behavioural therapy as the active comparator, as this has been shown to have helpful results for patients with pain.


This Evidence Summary is based on the following article:

Boersma K, Sodermark M, Hesser H, et al. Efficacy of a transdiagnostic emotion-focused exposure treatment for chronic pain patients with comorbid anxiety and depression: a randomized controlled trial. Pain. 2019 Apr 6. doi: 10.1097/j.pain.0000000000001575. PubMed

Published: Tuesday, July 23, 2019