Behavioral health is a core component of first-line, non-opioid treatment for chronic pain in most major medical guidelines, including the Centers for Disease Control and Prevention, the American College of Physicians, the World Health Organization, the American Academy of Neurology, the American Headache Society, and the American College of Gastroenterology. And yet, the concept of behavioral health to treat chronic pain still surprises many people, including many physicians.
Many people still hold a deeply ingrained dualistic view of the brain and body, that each is a completely separate system, and that chronic pain must be generated from an ongoing specific structural source identified through imaging or other testing, then managed through interventional procedures. Within that dualistic framework, the recommendation of behavioral health as a first-line treatment can feel counterintuitive, like a dismissal of the “real” source of pain. Often, an initial reaction to the introduction of a combined or integrated brain and body system can be defensive: “Are you telling me that this is all in my head?”
A true integrated understanding of how the brain and body function as one helps clarify the importance of addressing all of the different facets that contribute to chronic pain. The ways our brains process both environmental and internal stimuli and signals are intertwined, making it clear that the best outcomes for a particular condition require an approach that treats more than the underlying structural issues; we must also consider how our bodies heal and respond to different external factors like sleep, stress, and other contextual drivers.
Despite broad clinical recommendations, this dualistic disconnect remains a prominently held belief. Consequently, behavioral health commonly remains absent from chronic pain care in many places. Yet the recommendation did not emerge arbitrarily. It stems from our growing scientific understanding of chronic pain and how it is affected by external and internal factors.
Neuroimaging has dramatically changed the way that we think about chronic pain. If someone steps on a nail or touches a hot tea kettle, their body pulls away almost instantly through a spinal reflex, long before the brain has fully processed the pain itself. If you examined that response on an fMRI scan, you’d see activity in the somatosensory cortex, insula, and other brain regions involved in processing physical sensation. However, in chronic pain, we see a much different pattern. Over time, pain processing shifts beyond the sensory regions and becomes more closely associated with the limbic system, where it becomes more readily associated with and influenced by contextual drivers. Ultimately, as pain moves from acute to chronic, there is a transition where it becomes less of a direct sensory signal and more of a learned response shaped by emotion, context, attention, and past experience.
In some cases, this shift causes the nervous system to become increasingly protective, a process known as central sensitization, in which the brain and nervous system can begin to anticipate danger and can even generate pain signals in the absence of ongoing physical injury. In this state, the system becomes overprotective and amplifies pain signals based on hypervigilance and the mere expectation of harm.
As a result, chronic pain can persist long after an underlying structural injury has healed, even when there’s no clear ongoing physical damage or threat to the body. For people living with chronic pain, the pain they are experiencing is anything but imagined or “just in their head”; it is indeed very real, and often indicative of a nervous system that has become highly sensitive and over-responsive to learned threat responses.
Thankfully, certain types of behavioral therapy, such as pain reprocessing therapy (PRT), cognitive behavioral therapy (CBT), and other evidence-based interventions, have been proven to rewire, reframe, and reprogram the nervous system, reducing the effects of central sensitization. Long-term studies, including trials like the Boulder Back Pain Study, suggest that these therapeutic approaches are not only durable, but much more effective than opiates alone.
Central sensitization is the key to why behavioral approaches are recommended as first-line care for patients with chronic pain. As a result, one of the most beneficial things that a physician can do when evaluating a patient is recognizing when central sensitization is part of the clinical picture. Moreover, it is crucial for clinicians to understand how much of the pain that their patient is experiencing is being driven by ongoing physical injury versus a sensitized nervous system. Effective pain care is rooted in recognizing the role of central sensitization in chronic pain, and then ensuring that guidelines and recommendations are followed, including the involvement of behavioral health as a first-line treatment. Ignoring the behavioral health component of chronic pain treatment would only be a disservice to our patients.
Despite the ongoing belief of dualism, we understand that brain health affects personality, cognition, and emotion, and that psychological states can affect physical health and a variety of other bodily functions. The mind and body are not separate systems at all, but deeply interconnected and constantly influencing one another.
As a result, modern chronic pain care is no longer focused on simply addressing structural damage alone, but is a concerted effort to understand how the nervous system can become overprotective and contribute to maladaptive signaling and interpretation, and how behavioral treatment can help rewire, reframe, and recalibrate that system as an essential part of recovery.
Eric Anderson is a physician executive.
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