203: The Brain Mechanisms of Psychotherapy for Chronic Pain: A Systematic Review of Neuroimaging Studies

Topic: Clinical Science
Subtopic: Non-specific to any diagnosis, Psychology, Treatment/management , Imaging (e.g. fMRI, PET, MRS)

Background and Aims: Psychotherapeutic interventions can be effective treatments for chronic pain (CP). Yet, few studies have investigated the brain mechanisms underlying their effects using structural or functional magnetic resonance imaging (MRI) techniques. Characterizing how psychotherapy influences conceptual brain systems implicated in CP is critical for advancing a basic science of treatment effectiveness and warrants focused review. The aims of this systematic review were to (1) identify brain mechanisms of psychotherapy for CP; (2) establish which brain regions and measures are potential mediators of change; and (3) determine whether parameters of published studies converge in ways that allow replication and comparison of findings.

Methods: In accordance with PRISMA guidelines, we searched the PsychINFO, PubMed, Cochrane CENTRAL, and Scopus databases during September 2025. The following inclusion criteria were used to identify eligible articles: (1) Peer-reviewed RCTs; (2) Published in English; (3) Inclusion of a psychotherapeutic treatment; (4) Inclusion of adult CP patients (for both treatment and control groups); (5) Presentation of structural or functional MRI measures; (6) Inclusion of outcome measures assessing clinical pain; (7) Inclusion of both a pre-treatment and at least one post-treatment MRI scan session.

Results: Our search and screening yielded 21 neuroimaging studies published from 14 separate RCT patient cohorts. The insular cortex was the most frequently affected brain region by psychotherapy compared to control conditions across studies, followed by different areas of the cingulate, prefrontal, and sensorimotor cortices. Several significant alterations in brain function or structure following psychotherapy were significantly related to various improvements in both pain and other clinical outcomes across studies. However, substantial heterogeneity in RCT design parameters limited the direct comparison and replication of findings across studies in this area.

Conclusions: This systematic review provides a foundation for future studies aiming to investigate the brain mechanisms of psychological interventions for CP patients with functional or structural MRI. Psychological interventions appear to engage multiple conceptual brain systems in the context of CP, including those implicated in (1) the ascending and descending communication of nociceptive information, (2) fear and reward-related affective behavior(s), and (3) high-order systems supporting self-regulation and negative self-referential processes like pain catastrophizing. Continued mapping of the neurobiological effects of psychological interventions across these systems represents a valuable direction for evaluating and enhancing treatment effectiveness.

References: -

Presenting Author: David M. Gantz
Submitting Author: David Gantz

Senior Author: Tor D. Wager

IASP 2026 Global Year theme of Neuropathic Pain: No

• David M. Gantz: MA - Dartmouth College
• Lene Vase: PhD - Aarhus University
• Christopher Eccleston: PhD - The University of Bath
• Tor D. Wager: PhD - Dartmouth College