People experiencing difficult neurologic conditions such as migraine, low-back pain, and neuropathy are often treated with medication, physical therapy, or surgery. Increasingly, physicians are prescribing another option to help ease symptoms: cognitive behavioral therapy (CBT). A form of talk therapy, CBT relies on behavior-based solutions to manage emotional and physiological challenges. A growing body of research suggests it can be just as effective as medication and other types of treatment, either on its own or in conjunction with them.
"A central principle of CBT is that what you believe affects your behavior and emotions. The therapy helps identify and reframe thoughts and beliefs that have unwanted emotional and behavioral impacts," says Lisa Napolitano, PhD, founder of CBT/DBT Associates in New York City, who works closely with neurologists at NYU School of Medicine. Traditionally, CBT has been used to help people manage depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, and eating disorders-sometimes in a relatively short amount of time (five to 20 sessions with a therapist) and without the use of medication.
In CBT, patients are assigned homework or self-therapy exercises that reinforce what was discussed at their sessions. "CBT involves instruction, usually by a therapist or a psychologist, daily attention to thoughts and feelings, and applying session work to your everyday life," says Mia T. Minen, MD, MPH, chief of headache research at NYU Langone Health. Homework may include relaxation exercises and tracking progress in a notebook or online. "Over time, CBT teaches people how to adapt their behavior and modify their thoughts and feelings," says Dr. Minen.
"CBT helps patients become their own caretakers," adds Elizabeth K. Seng, PhD, associate professor of neurology at the Albert Einstein College of Medicine in New York City. "It helps patients change patterns in their thinking and habits that keep them from reaching their health and life goals."
While the therapy cannot cure a neurologic condition, it can help patients deal with symptoms. "CBT is a grade-A recommendation for migraine management and a first line of defense for insomnia," says Dr. Minen. "There are also well-established CBT protocols for Tourette syndrome, low-back pain, and chronic pain."
In addition, CBT can help patients comply with prescribed exercise, physical therapy, and other activities that may feel like chores. "Anyone managing a severe or chronic neurologic illness may have trouble adapting to their changed status and prognosis," says Dr. Seng. "CBT can target those challenges and help identify and address obstacles, such as fear of or procrastinating about making doctors' appointments, anxiety about taking medications, or insecurity about using necessary devices."
The first step in CBT is to find a CBT-trained therapist through a referral from a primary care physician or health insurance provider. The next step is to give some thought to what needs to change. Because CBT is goal-oriented, a therapist will ask patients what they want to focus on, whether it's managing pain, depression, or anxiety or adhering to prescribed physical therapy or medication. During each session, patients can expect to learn about their emotional and mental health and the thoughts and perceptions that keep them from managing their condition, such as anxiety about making necessary doctors' appointments or taking medication. Patients also learn relevant techniques, including stress reduction, relaxation, coping, and resilience.
Patients and their therapists identify any troubling situations and symptoms—such as pain or limited mobility—and the patients' thoughts and perceptions about them. For example, if you get migraines, you may experience anxiety as an attack is about to start. With CBT, you'll learn to develop habits that reshape negative thinking.
Dennis Tirch, PhD, founder of the NYC-based Center for Compassion-Focused Therapy, used CBT with a patient who had persistent daily headaches. "Through CBT, the patient realized he was more focused on feeling ashamed and judging himself about the way headaches interfered with his daily life than he was on engaging with family and his work," Dr. Tirch explains. "By redirecting his energy and awareness to what mattered most to him, he became less aware of the pain, and the pain became less debilitating." Dr. Tirch says the patient was able to tune out the pain as he would tune out background noises such as traffic or voices in the street. "Most CBT methods are focused on helping someone live with challenging neurologic symptoms rather than getting rid of them."
Dr. Minen and her team at NYU have developed a CBT app for headache patients that provides audio instruction in progressive muscle relaxation—alternately tensing and relaxing all muscle groups, which should ease the onset of a headache. According to a study of the app's effectiveness published in Nature Digital Medicine in 2019, patients who used it at least twice each week over the course of 90 days had fewer headache episodes than those who used it less frequently. Use of the app also appeared to improve anxiety and depression.
Researchers continue to investigate different applications for CBT. A study published in the Annals of Neurology in October 2019 found that the therapy and the antidepressant sertraline (Zoloft) were equally effective at relieving major depression in a group of people with epilepsy. And, Dr. Seng notes, CBT typically does not have the side effects associated with certain antidepressants, like fatigue, suicidal thoughts, nausea, constipation, and weight gain.
CBT has begun expanding to include other nontraditional techniques. "The next phase in the therapy's evolution emphasizes mindfulness," says Dr. Napolitano. Mindfulness teaches patients to remain in the moment rather than worrying about what might happen or has already happened, which can decrease anxiety and stress.
In a study published in the journal Headache in October 2019, Dr. Seng and colleagues reported that mindfulness-based cognitive therapy for migraine, which includes several CBT components, mitigated disability better than conventional migraine treatments did—meaning that even if patients didn't have fewer or less intense headaches, their ability to cope improved.
"CBT is focused on improving coping skills," says Scott E. Hirsch, MD, clinical associate professor of neurology at NYU School of Medicine. "When coping skills fail us, negative thoughts, emotions, and maladaptive behaviors may result. CBT can address these issues and restore patients' ability to cope."
How CBT Changes the Brain
We know that cognitive behavioral therapy (CBT) can change behavior. Does it also alter the way the brain works?
Neuroimaging has revealed that the thoughts and actions patients learn in CBT literally modify the brain's neural circuits—an example of neuroplasticity, the brain's ability to adapt over the course of a lifetime. According to a 2017 study in Molecular Psychiatry, for instance, neuroimaging showed structural changes in the areas of the brain linked to self-control in people with social anxiety disorder who underwent a 10-week course of CBT, says Lisa Napolitano, PhD, founder of CBT/DBT Associates in New York City. The study also showed that brain areas involved in processing emotions were more interconnected after CBT.
A review of 10 imaging studies in the Journal of Neuropsychiatry and Clinical Sciences indicated that the skills taught in CBT for depression appeared to cause positive changes to the same areas of the brain that are affected by common antidepressants, says Elizabeth K. Seng, PhD, associate professor of neurology at the Albert Einstein College of Medicine in New York City. She also cites a 2017 study evaluating a four-week CBT protocol designed to reduce anxiety in fibromyalgia patients that found a reduction in the brain activity specifically associated with extreme worry.
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For information about what to expect from CBT, read "What to Expect from a Cognitive Behavioral Therapy Session."
