Chronic Pain & Somatic Symptoms
Somatic Symptom and Related Disorders (DSM-5-TR)
This topic groups chronic primary pain, pain associated with an underlying condition, and distinct somatic-symptom or illness-anxiety presentations. These require separate assessments and should not share a single treatment-evidence claim.
Sources for the corrected statements:
Prevalence: ~24% of US adults had chronic pain and ~9% had high-impact chronic pain in 2023 (NCHS, National Health Interview Survey)
Clinical Picture
Chronic pain challenges the mind-body split that runs through Western medicine and much of psychotherapy. Pain is simultaneously a neurobiological event, a psychological experience, and a social phenomenon, and treatment that addresses only one dimension tends to fail. The biopsychosocial model is the accepted framework, but in practice, clients with chronic pain are often shuttled between medical providers ('there's nothing structurally wrong') and mental health providers ('it's all in your head'). Neither is adequate. Effective treatment validates the reality of pain while expanding the client's understanding of how psychological and social factors modulate the pain experience.
Treatment Considerations
Chronic primary pain, pain due to an underlying condition, and somatic-symptom presentations need separate assessments. NICE NG193 says to consider pain-focused CBT or ACT for chronic primary pain from age 16, delivered by appropriately trained professionals. Quality of life can improve even when pain does not. These recommendations do not verify the page’s other therapies or a claim that body-based trauma approaches outperform cognitive care. NG193 says not to offer biofeedback for chronic primary pain. Its separate review of relaxation, mindfulness and psychotherapy found too little evidence for recommendations, while acknowledging possible benefit; the psychotherapy research recommendation specifically concerns psychodynamic therapy. Lack of a recommendation is not proof of ineffectiveness. For secondary pain or coexisting primary and secondary pain, use the relevant condition guidance and shared clinical judgement.
Sources for the corrected statements:
Approaches and Evidence
Of 21 associated approaches, 2 have completed assessments for this topic, 4 have source checks awaiting assessment, and 15 have neither recorded yet. Each completed assessment states its population and rationale; source checks alone do not establish effectiveness. These categories describe different findings and review stages; they are not a ranking of treatments.
Guideline recommendation (2)
These assessments record a guideline recommendation for the stated population. Read the scope and rationale; a broad topic label does not make a recommendation applicable to everyone.
Acceptance and Commitment Therapy
Steven Hayes · 1999
Reviewed population: People aged 16 and over with chronic primary pain, receiving ACT from an appropriately trained healthcare professional; distinguished from the broader adult chronic-musculoskeletal-pain question.
NICE NG193 1.2.3 says to consider ACT; its rationale reports benefits but a small study base and no preference over CBT. APA’s 2024 guideline separately found evidence insufficient to recommend ACT over active control or usual care for adult chronic musculoskeletal pain. These scopes and judgments differ. The label records NICE’s qualified recommendation, not unanimous support or evidence for all pain or somatic-symptom presentations.
Reviewed
Guidelines and official sources (7)
6 clinical guideline checks · 1 evidence registry check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Acceptance and commitment therapy for chronic pain
Discussed in the source
The archive lists Strong under 1998 criteria, with 2015 re-evaluation pending.
Scope: ACT for chronic pain
- Chronic pain (primary and secondary) in over 16s (NG193)
Recommendation for the stated population
NICE says to consider ACT or CBT for pain, delivered by appropriately trained professionals.
Scope: People aged 16 and over with chronic primary pain
- Clinical Practice Guideline for the Non-Surgical Management of Hip and Knee Osteoarthritis
Discussed in the source
The appendix names ACT as an optional psychosocial or behavioral intervention, guided by availability and patient preference. This is ungraded implementation guidance, not a separately graded osteoarthritis recommendation.
Scope: Conceptual approach to chronic primary (nociplastic) pain when self-management strategies are insufficient.
- Diagnosis and Treatment of Low Back Pain
Discussed in the source
The review found no eligible ACT studies and identifies comparative ACT research as a priority. The CBT recommendation should not be presented as a separate ACT endorsement.
Scope: ACT evidence considered in the chronic low back pain review.
- Management of Headache
Discussed in the source
The recommendation is neutral for the mindfulness-based therapy category; the discussion includes ACT. It does not assign ACT a separate recommendation grade.
Scope: Mindfulness-based interventions for headache treatment or prevention.
- Primary Care Management of Chronic Kidney Disease
Discussed in the source
The appendix names ACT among behavioral pain-management options, selected by availability and preference. This is ungraded guidance; much supporting evidence comes from people without kidney disease.
Scope: Adults with chronic kidney disease and chronic pain; self-management insufficient.
- Clinical Practice Guideline for Psychological and Other Nonpharmacological Treatment of Chronic Musculoskeletal Pain in Adults
Insufficient evidence for or against
APA finds the evidence insufficient for a recommendation in these comparisons. This is not a finding of ineffectiveness.
Scope: Adults with chronic musculoskeletal pain; ACT versus active control or usual care.
Cognitive Behavioral Therapy
Aaron Beck · 1964
Reviewed population: People aged 16 and over with chronic primary pain, receiving CBT specifically adapted for pain from an appropriately trained healthcare professional.
NICE NG193 1.2.3 says to consider pain-focused CBT. Its rationale describes quality-of-life benefits, inconsistent effects on other outcomes and evidence limitations; it does not establish reliable pain reduction or superiority to ACT. This assessment does not cover every secondary pain condition, somatic symptom disorder or generic CBT.
Reviewed
Guidelines and official sources (9)
9 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Clinical Practice Guideline for the Non-Surgical Management of Hip and Knee Osteoarthritis
Discussed in the source
The appendix names CBT as an optional psychosocial or behavioral intervention, guided by availability and patient preference. This is ungraded implementation guidance, not a separately graded osteoarthritis recommendation.
Scope: Conceptual approach to chronic primary (nociplastic) pain when self-management strategies are insufficient.
- Clinical Practice Guideline for the Management of Chronic Multisymptom Illness
Recommendation for the stated population
VA/DoD weakly recommends CBT, drawing substantially on indirect evidence from these symptom syndromes. This is a recommendation for managing symptoms and function, not a claim that the illness is psychological or that CBT cures it.
Scope: Chronic multisymptom illness and symptoms consistent with fibromyalgia, IBS, or ME/CFS.
- Diagnosis and Treatment of Low Back Pain
Recommendation for the stated population
VA/DoD suggests CBT for chronic low back pain with a weak recommendation. This is narrower than a recommendation for every pain condition or acute low back pain.
Scope: Adults with chronic low back pain.
- Management of Headache
Insufficient evidence for or against
VA/DoD finds insufficient evidence for or against CBT for headache. This neutral recommendation is not a recommendation against treatment.
Scope: CBT for headache treatment or prevention.
- Use of Opioids in the Management of Chronic Pain
Discussed in the source
The algorithm lists CBT as a non-opioid psychological treatment option. This sidebar is not a separately graded CBT recommendation or an opioid-use-disorder treatment guideline.
Scope: Non-opioid options within chronic pain care.
- Primary Care Management of Chronic Kidney Disease
Discussed in the source
The appendix names CBT among behavioral pain-management options, selected by availability and preference. This is ungraded guidance; much supporting evidence comes from people without kidney disease.
Scope: Adults with chronic kidney disease and chronic pain; self-management insufficient.
- Clinical Practice Guideline for Psychological and Other Nonpharmacological Treatment of Chronic Musculoskeletal Pain in Adults
Recommendation for the stated population
APA strongly recommends offering CBT for this comparison.
Scope: Adults with chronic musculoskeletal pain; CBT versus usual care or another active intervention.
- Clinical Practice Guideline for Psychological and Other Nonpharmacological Treatment of Chronic Musculoskeletal Pain in Adults
Discussed in the source
APA reports insufficient evidence for this comparison. The table groups these approaches without assigning separate protocol grades.
Scope: Knee osteoarthritis; the reviewed CBT/motivational-interviewing/pain-coping-skills category versus usual care.
- Chronic pain (primary and secondary) in over 16s (NG193)
Recommendation for the stated population
NICE says to consider pain-focused CBT; outcomes and evidence limitations are described separately from other pain diagnoses.
Scope: Chronic primary pain, age 16 and over; trained pain-focused CBT.
Source checks available — assessment pending (4)
Sources have been checked for this topic, but a condition-specific assessment has not been completed. Open the source notes to read each document’s population, recommendation and limitations.
Biofeedback
Various (Neal Miller / Kamiya / Green / Sterman / Schwartz) · 1960
Guidelines and official sources (4)
4 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Chronic pain (primary and secondary) in over 16s (NG193)
Recommendation against the stated use
NICE says not to offer biofeedback for chronic primary pain. This is a specific pain recommendation, not a judgment about every biofeedback application.
Scope: People aged 16 and over with chronic primary pain
- Clinical Practice Guideline for the Management of Chronic Multisymptom Illness
Insufficient evidence for or against
VA/DoD finds insufficient evidence for or against biofeedback modalities. The review includes physiological and HRV biofeedback; it is not a brand-specific HeartMath recommendation.
Scope: CMI and symptoms consistent with fibromyalgia, IBS, or ME/CFS.
- Diagnosis and Treatment of Low Back Pain
Discussed in the source
The guideline reports that no biofeedback studies met this review’s inclusion criteria. It does not make a separately graded biofeedback recommendation or establish that no studies exist.
Scope: Biofeedback evidence considered in the low back pain review.
- Management of Headache
Insufficient evidence for or against
VA/DoD finds insufficient evidence for or against these interventions for headache. The discussion focuses on a smartphone biofeedback trial; the recommendation is not a broad efficacy rating for other conditions.
Scope: Biofeedback and smartphone-based heart-rate variability monitoring for headache treatment or prevention.
Clinical Hypnotherapy
Milton Erickson · 1950
Guidelines and official sources (2)
2 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Irritable bowel syndrome in adults: diagnosis and management (CG61)
Recommendation for the stated population
NICE says to consider referral for psychological interventions including hypnotherapy. The recommendation is IBS-specific, not for pain generally.
Scope: Adult refractory IBS continuing after 12 months without response to drug treatment.
- Clinical Practice Guideline for the Management of Chronic Multisymptom Illness
Insufficient evidence for or against
VA/DoD finds insufficient evidence for or against guided imagery and hypnosis modalities in this population. The neutral finding does not extend to every clinical use of hypnosis.
Scope: CMI and symptoms consistent with fibromyalgia or IBS.
HeartMath
Doc Childre · 1991
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Management of Headache
Discussed in the source
The guideline is neutral for this intervention category. It does not name or endorse HeartMath; a category-level source cannot establish a product-specific recommendation.
Scope: Biofeedback and smartphone-based heart-rate variability monitoring for headache.
Mindfulness-Based Stress Reduction
Jon Kabat-Zinn · 1979
Guidelines and official sources (4)
4 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Clinical Practice Guideline for the Management of Chronic Multisymptom Illness
Discussed in the source
VA/DoD weakly recommends the mindfulness-based therapy family and discusses MBSR in fibromyalgia. It does not separately grade MBSR or establish its benefit for every syndrome covered by the guideline.
Scope: MBSR studied in fibromyalgia within the chronic multisymptom illness guideline.
- Diagnosis and Treatment of Low Back Pain
Insufficient evidence for or against
The current guideline finds insufficient evidence for or against MBSR. Its appendix also reproduces the older positive recommendation; that historical wording is not the 2022 recommendation.
Scope: Adults with chronic low back pain.
- Management of Headache
Discussed in the source
The recommendation is neutral for the mindfulness-based therapy category; the discussion includes MBSR. It does not assign MBSR a separate recommendation grade.
Scope: Mindfulness-based interventions for headache treatment or prevention.
- Clinical Practice Guideline for Psychological and Other Nonpharmacological Treatment of Chronic Musculoskeletal Pain in Adults
Recommendation for the stated population
APA conditionally suggests MBSR, considering patient preferences.
Scope: Adults with chronic low-back pain; MBSR versus usual care, attention control, or another intervention.
Assessment not yet completed (15)
No completed assessment or source check for this topic is recorded yet.
Brainspotting
David Grand · 2003
Cognitive Behavioral Therapy for Insomnia
Bootzin / Spielman / Morin / Perlis · 1987
Craniosacral Therapy
John Upledger · 1970
Dance/Movement Therapy
Marian Chace · 1942
Emotional Freedom Techniques (EFT Tapping)
Gary Craig · 1995
Eye Movement Desensitization and Reprocessing
Francine Shapiro · 1989
Feldenkrais Method
Moshé Feldenkrais · 1949
Focusing
Eugene Gendlin · 1978
Internet-Delivered Cognitive Behavioral Therapy
Various (Andersson / Titov) · 2000
Intensive Short-Term Dynamic Psychotherapy
Habib Davanloo · 1980
Ketamine-Assisted Psychotherapy
Various (Wolfson, Bennett) · 2010
Music Therapy
Nordoff / Robbins · 1950
Short-Term Psychodynamic Psychotherapy
Davanloo / Sifneos / Malan · 1968
Somatic Experiencing
Peter Levine · 1997
Sound Therapy / Therapeutic Sound
Various (Mitchell Gaynor, Jonathan Goldman, Don Campbell) · 1990
Additional Source References (3)
These source checks also address this topic. They are listed separately from the catalogue associations above. Read each source’s scope and direction; a mention may concern a related intervention or a neutral recommendation.
Mindfulness-Based Cognitive Therapy
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Management of Headache
Discussed in the source
The recommendation is neutral for the mindfulness-based therapy category; the discussion includes MBCT. It does not assign MBCT a separate recommendation grade.
Scope: Mindfulness-based interventions for headache treatment or prevention.
Motivational Interviewing
Guidelines and official sources (2)
2 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Use of Opioids in the Management of Chronic Pain
Discussed in the source
MI appears among non-opioid care options and in tapering studies. The guideline weakly supports collaborative tapering but is neutral on specific tapering strategies; it does not separately grade MI.
Scope: Chronic pain care and collaborative opioid tapering.
- Clinical Practice Guideline for Psychological and Other Nonpharmacological Treatment of Chronic Musculoskeletal Pain in Adults
Discussed in the source
APA reports insufficient evidence for this comparison. The table groups these approaches without assigning separate protocol grades.
Scope: Knee osteoarthritis; the reviewed CBT/motivational-interviewing/pain-coping-skills category versus usual care.
Neurofeedback
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Clinical Practice Guideline for the Non-Surgical Management of Hip and Knee Osteoarthritis
Insufficient evidence for or against
VA/DoD finds insufficient evidence for or against neurofeedback in this population. This does not establish its status for other conditions.
Scope: Treatment of hip or knee osteoarthritis.
Cases Featuring Associated Approaches
These teaching cases share approach links with this topic. They may illustrate a different presenting concern.
Reading This Page
Why are these approaches listed with Chronic Pain & Somatic Symptoms?
The catalogue associates 21 approaches and 0 frameworks with this topic. These links support learning and comparison; association alone is not a treatment recommendation or evidence of effectiveness.
How should I read the evidence assessments?
Assessments are specific to the population and scope stated on each card. They include a rationale, source links, and a review date. An overall review of an approach does not automatically apply to this condition, and a randomized-study label does not by itself mean that a study found benefit.
What does "Assessment not yet completed" mean?
A condition-specific assessment has not been recorded. Approaches with checked sources appear in a separate assessment-pending group; a checked source can support, oppose, or discuss an intervention without recommending it. Neither pending group means that no research exists or that the approach is ineffective. Frameworks are shown separately.
Sources and Review Scope
Source links and dates on assessment cards apply to the stated population and rationale. The clinical overview and prevalence text above are separate authored content; an approach's evidence label does not verify those statements. Recorded narrative notes and citations remain available on individual modality pages, with their review status identified. The bibliography provides further reading.