Psychological Assessment of Chronic Pain Patients

CHAPTER 7 PSYCHOLOGICAL ASSESSMENT OF CHRONIC PAIN PATIENTS



Dennis Thornton, PhD, Charles E. Argoff, MD




1. Why is a good psychological assessment essential?


The purpose of a psychological evaluation is to frame the pain experience in the context of a patient’s life. Specifically, it evaluates the impact of pain on the patient’s functioning and the role that the patient’s psychological makeup has in the experience of pain. It is not designed to differentiate between organic and psychogenic pain. The evaluation should, however, assess the impact of anxiety, depression, and prior life experiences on pain. Assessing personality characteristics provides a means of helping the patient to maximize treatment efforts and minimize resistance.



2. Does gender mediate an individual’s response to pain?


Gender-related differences have been studied clinically and experimentally. Women are at greater risk of developing some specific chronic pain disorders and are more sensitive to experimentally induced pain than are men. Psychosocial factors, such as role beliefs, affective state, coping strategies, employment status, pain-related expectancies, hormonal effects, familial modeling, and intergenerational influences may exert a role in the observed differences.



3. Do race and ethnicity exert an influence on the pain experience and response?


As with gender-related issues, the influence of ethnic background on the response to acute clinical, experimental, and chronic pain has been investigated extensively over the decades. Differences observed in a wide variety of settings have sometimes been confusing and contradictory. As with gender-related issues, the reader is encouraged to avoid overemphasis on any one article or research report and to survey the broad spectrum of literature to see the stated differences in context.



4. What is the essential element of a good pain evaluation?


The essential element of a good pain evaluation is that the clinician believes that the pain is real! Whether or not an organic framework can be defined is somewhat less important in chronic pain than it is in acute pain. However, both physical and psychological issues must be addressed on the first visit.



5. What data-collecting strategies can be employed to render a comprehensive assessment of the patient with chronic pain?


From the psychological perspective, patient involvement is essential to the pain assessment process. There are a number of tools available for self-reporting, including pain and activity diaries. These tools can provide an index of the following:



image Pain intensity and characteristics


image Onset and evolution of the pain syndrome


image Patient attributions


image Patient outlook on his or her condition


image Personal and family background


image Projected functional goals


image Mood


Additionally, evaluation of behavioral responses from significant others can be enlightening. Whenever possible, collect naturalistic observations; they are invaluable. Try to observe the patient while he or she is engaged in routine activities and (ideally) unaware of your attention. Canvass secretaries and allied staff for their interactions with the patient.



6. What methods can be used for the psychological assessment of patients with chronic pain?


The psychological interview can be supported by a number of “pencil-and-paper” indices. The interview should establish a conceptual framework, and the pencil-and-paper tests can be used to facilitate patient communication in order to quantify such issues as pain intensity, severity of mood disorder, and level of function.



7. What factors commonly interfere with the accurate assessment of chronic pain?


Pain is an entirely subjective experience. Therefore, personal factors impact the process and accuracy of pain assessment. Cultural, ethnic, and linguistic patterns may influence both how the pain is expressed and how it is interpreted. Furthermore, clinicians are classically trained in the biomedical model, in which pain is believed to be due to a clearly identifiable point of tissue injury. In chronic pain, this may no longer be the case. A shift must occur to a biopsychosocial model, in which the complaint of pain is viewed in a more global framework.



8. What is the most common conceptual mistake that the examining clinician makes?


Physicians often try to conceptualize pain as either organic or psychological (“psychosomatic”). This dichotomy is rarely absolute. True delusional pain is extraordinarily rare. Most commonly, psychological factors impact on the expression of pain, and pain has its impact on a patient’s psychological well-being.



9. How important are behavioral signs in assessing pain intensity in chronic pain?


The autonomic “flight-or-fight response” that we commonly associate with acute pain is often lacking in chronic pain. Therefore, tachycardia, diaphoresis, and agitation are often absent. Over time, patients adapt to chronic pain. This adaptation may be appropriate or inappropriate, given the circumstances. Similarly, signs of emotional distress may be replaced by a blunting of affect.



10. Is there a specific format for interviewing patients with pain?


Interviews must be tailored to fit the situation. However, there is structure to the interview process. A biopsychosocial format is the most appropriate. It starts with the patient’s complaint, which is clearly foremost in his or her mind. Aside from the usual questions regarding intensity, location, and character, the psychosocial variables to be addressed include the circumstances under which the pain began, its duration, the success or failure of various interventions, the patient’s responses to these treatments and results, the impact of the pain on the patient’s life, and the patient’s expectations or goals of treatment.



11. Why is determining the time of onset important?


The circumstances under which the pain arose may give some insight into the psychological phenomenon surrounding the pain syndrome. For example, traumatic injuries, such as motor vehicle accidents or major surgeries, may give rise to a posttraumatic stress disorder. Diseases with an insidious onset and an exacerbating-remitting course may provoke anxiety with each exacerbation of pain. If the pain syndrome was the result of a co-worker’s negligence, poorly directed anger may be a significant component. Similarly, litigation and compensation surrounding an injury may be important factors.



12. Describe psychological insights that can be gained from reviewing treatments that have failed


Patterns of response and nonresponse may imply certain specific psychological syndromes. For example, patients who claim dramatic relief from certain treatments, only to fail a short while after, may be engaging in idealization/demystification. This is typical of the hysterical personality disorder and may put the clinician at great risk for defeat. Similarly, patients who are unable to tolerate any medications, describing bad reactions to all, may be unconsciously sabotaging treatment. Thus, a careful history of all prior treatments, successful or otherwise, can be a guide to expectations of future interventions.


The same is true of the patient’s perception of the prior treating clinicians. Much the same as a treatment can be rapidly valued and devalued, the same holds for a treating clinician.



13. Is emotional distress a normal consequence of illness and pain? What does the absence of such a response imply?


Serious illness, especially when accompanied by pain, raises numerous anxieties. Patients may fear very significant illness, incapacitation, or death. If they emphatically deny any anxiety or emotional impact, it is likely that these emotions are threatening to the patient and require further psychological evaluation. Patients may also intentionally minimize or deny psychological distress for fear that their complaints of pain will be interpreted as “psychosomatic” and they will be labeled as “crazy.”



14. What strategies can be employed to elicit the psychological impact of pain if a patient is unable to express it?


The first step is to put the patient at ease by suggesting that psychological reactions to pain are quite normal. Cite some specific examples, such as posttraumatic stress disorder after war injuries, motor vehicle accidents, traumatic surgeries, and so on. Should this fail, it may be helpful to interview family members and significant others. They can describe pain behaviors, drug use patterns, altered functional roles, and mood changes. In addition, observing the interaction between the patient and significant others may provide useful insights into family dynamics and level of frustration.



15. Why is the assessment of functioning and level of distress so important?


Increasingly, clinical observation and research have highlighted functioning and level of distress because these factors are related to disability. More than pain intensity, performance difficulties and negative affect are statistically linked with greater disability. Difficulties in performing premorbid roles and activities erode self-esteem and hopefulness. The ensuing negative affect can foster a sense of giving up, which will help establish and perpetuate disability status.



16. What specific areas of function should be addressed?


Question the patient about his or her ability to work (both outside the house and in relation to the usual household duties) and the impact on social life, mood, sleep, sexual activity, and relationships with others.



17. What specific work-related issues should be addressed?


Determine what the patient’s prior work status was and the feasibility of his or her returning to that type of work. Specifically, ask questions about the amount of skill required for the job, physical qualifications, and job satisfaction. The financial impact of working versus collecting disability payments should also be addressed. Also investigate the patient’s work history with regard to relative job satisfaction, progress on the job, and time lost because of pain or illness.



18. How can chronic pain affect social function?


Chronic pain can impede a patient’s ability to seek gainful employment. If the patient was originally the breadwinner, this role as head-of-household and power figure may diminish. Correspondingly, self-esteem may diminish, and the patient’s interactions will necessarily change as a result. Pain may limit a patient’s social sphere. In certain instances, this may actually serve a subconscious psychological function. Most commonly, patients complain that the pain strips them of their desire to interact with other people and that they feel “too tired to do anything.”



19. What are the normal affective reactions to chronic pain?


It is probably more useful to define affective reactions as adaptive or maladaptive rather than normal or abnormal. Frustration and irritability are common affective reactions, but the emotional energy can be channeled into job rehabilitation—an adaptive use of those emotions. Reactions that lead to insomnia and social isolation are maladaptive.



20. How can family members influence the patient’s response to pain?


In classic behavioral theory, certain behaviors are reinforced and others are discouraged. Although some degree of solicitousness on the part of a spouse or caretaker is appropriate for a patient in pain, excessive attention to the complaint may lead to infantilization and less adaptive behaviors by the patient. Directly question families about how they react to the patient’s pain complaints or behaviors.



21. Why should family dynamics be assessed?


In certain circumstances, family interactions can serve to perpetuate pain. For example, if a couple has been at odds, they may unite to combat a common enemy (the pain). When this happens, they have an investment in maintaining the complaint of pain to shift focus away from their own problems.



22. Why are questions about sexual activity important?

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Jun 14, 2016 | Posted by in PAIN MEDICINE | Comments Off on Psychological Assessment of Chronic Pain Patients

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