Tools That Should Be Considered in Pain Assessment: Cognitive Factors, Emotion, and Personality


Domain
 
Instrument

Neuropsychologya

Intelligence

KAIT, NART, RPM, WAIS-IV

Executive function

BADS, Brixton Spatial Anticipation Test, CANTAB, Digit Span, D-KEFS, Fluency, Hayling Sentence Completion Test, Stroop Color/Word test, TMT, Tower of London/Hanoi, WCST

Memory

BVRT, CVLT-II, HVLT, LLT, RAVLT, RBMT 3, WMS-IV

Attention processing speed

CPT, d2, TEA, TMT-A, Stroop Word and Color cards

Malingering and insufficient effort

MMPI, Rey 15-item Memory test, SIMS, TOMM, WMT

Pain Cognitionsa

Catastrophizing, control beliefs, attitudes

BPCQ, CSQ, MLPC, PAQ, PBPI, PBQ, PCL, PCS, SOPA

Emotiona

Depression

BDI-II, CES-D, DASS, GDS, HADS, HRSD, ZDS

Anxiety

BAI, DASS, FPQ, HADS, HARS, PASS, STAI

Personalitya

Extraversion, neuroticism, depression

Cattell’s 16PF, EPI, HEXACO Personality Inventory, MMPI, NEO-PI

Lack of anxiety and fear, coldheartedness

PCL-R, PPI


BADS Behavioural Assessment of the Dysexecutive Syndrome, BAI Beck Anxiety Inventory, BDI Beck Depression Inventory, BPCQ Beliefs about Pain Control Questionnaire, BVRT Benton Visual Retention Test, Cattell’s 16PF Cattell’s 16 Personality Factor Test, CANTAB Cambridge Neuropsychological Test Automated Battery, CES-D Center for Epidemiological Studies Depression Scale, CPT Continuous Performance Test, CSQ Coping Strategies Questionnaire, CVLT California Verbal Learning Test, DASS Depression Anxiety Stress Scale, D-KEFS Delis-Kaplan Executive Function System, EPI Eysenck’s personality Inventory, FPQ Fear of Pain Questionnaire, GDS Geriatric Depression Scale, HADS Hospital Anxiety and Depression Scale, HARS Hamilton Anxiety Rating Scale, HRSD Hamilton Rating Scale for Depression, HVLT Hopkins Verbal Learning Test, KAIT Kaufman Adult Intelligence Test, LLT Location Learning Test, MLPC Multidimensional Locus of Pain Control Questionnaire, MMPI Minnesota Multiphasic Personality Inventory, NART National Adult Reading Test, NEO-PI NEO Personality Inventory, PASS Pain Anxiety Symptom Scale, PAQ Pain Attitudes Questionnaire, PBPI Pain Beliefs and Perception Inventory, PBQ Pain Beliefs Questionnaire, PCL Pain Cognition List, PCL-R Psychopathy Checklist-revised, PCS Pain Catastrophizing Scale, PPI Psychopathic Personality Inventory, RAVLT Rey Auditory Verbal Learning Test, RBMT Rivermead Behavioural Memory Test, RPM Raven Progressive Matrices, SIMS Structured Inventory of Malingered Symptomatology, SOPA Survey of Pain Attitudes, STAI State-Trait Anxiety Inventory, TEA Test of Everyday Attention, TMT Trail Making Test, TOMM Test of Memory Malingering, WAIS Wechsler Adult Intelligence Scale, WCST Wisconsin Card Sorting Test, WMS Wechsler Memory Scale, WMT Word Memory Test, ZDS Zung Depression Scale

aThe functions within each domain represent a selection of those aspects relevant in relation to pain assessments; naturally, each domain encompasses more aspects than currently denoted in this table






6.5 Pain Tools and Different Components


Different tools are currently employed for pain assessment purposes; for an overview, see McDowell (2006). The most widely used include the McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), the Chronic Pain Grade (CPG), the Oswestry Low Back Pain Disability Questionnaire, visual analogue scale (VAS), numerical rating scale, Short Form 36 Bodily Pain Scale (SF-36 BPS), Faces Pain Scale (FPS), Verbal Descriptor Scale, and Self-Rating Pain and Distress Scale. When distinguishing between the different pain components, scales such as the MPQ are useful. In case of cognitive impairment, scales such as the FPS and VAS may be less reliable; additional information from observation tools is advisable then.

The literature on factors contributing to pain reports and experience is extensive. Sometimes, controversial findings have been reported, which may be due to factors such as differences in study design and the different pain components that have been assessed. Next to a distinction between findings that result from either clinical or experimental pain assessment methods, a crucial differentiation is one between different pain components, such as sensory and cognitive-evaluative or affective-emotional aspects, since the processing of these aspects relies on different neural pathways. For example, whereas the processing of sensory-discriminative pain component relies on more posterior brain structures as well as the primary and secondary somatosensory areas (the “lateral pain system”), the cognitive-evaluative and affective-emotional aspects are primarily being processed by frontal-limbic brain regions (the “medial pain system”). This system includes brain regions also heavily involved in cognitive functions (e.g., dorsolateral prefrontal region, anterior cingulate cortex, hippocampal formation) as well as in the processing of affective information such as fear and anxiety (e.g., orbitofrontal and ventromedial prefrontal cortex, amygdala). This overlap is evident in studies showing interrelatedness between pain reports and cognitive, psychological, and personality measurements.

In experimental pain studies, consistent patterns of results have been observed showing particular overlap between medial pain aspects on the one hand and emotional or cognitive aspects on the other. In patients with fibromyalgia, for example, depressive symptoms were found to be associated with neural activation patterns in those brain regions associated with affective pain processing, but not with the more sensory-discriminative pain pathway (Giesecke et al. 2005). Similarly, several studies showed that mood induction alters pain tolerance, but not pain intensity levels (e.g., Loggia et al. 2008; Kut et al. 2011; Villemure et al. 2003). Cognitive inhibition is also significantly associated with pain tolerance levels, but not with pain threshold (Oosterman et al. 2010a). Some studies do not, however, support this overlap, in that emotion induction has also been associated with both altered pain intensity and unpleasantness ratings in healthy controls (Kamping et al. 2013).


6.6 The Overlap Between Cognition, Emotion, and Personality in Relation to Pain


From the previous sections, it is evident that both personality/emotional and cognitive factors are significantly associated with clinical and experimental pain reports. The extent to which these factors are interrelated is unclear as the evidence is unequivocal. For example, in fibromyalgia patients, neuroticism and conscientiousness are associated with catastrophizing, whereas neuroticism, agreeableness, and openness relate to pain anxiety. Similarly, another study showed that factors such as fear and catastrophizing are strongly associated with negative personality constructs (e.g., neuroticism, Lee et al. 2010). Catastrophizing may mediate the relationship where higher dispositional optimism is associated with reduced endogenous pain facilitation responses (Goodin et al. 2013). Finally, significant associations have been reported between pain cognitions and personality constructs such as neurotic traits, depression, and anxiety (Williams et al. 1994).

On the other hand, evidence regarding the relationship between cognitive functioning and emotional/personality constructs is less conclusive. For example, both cognitive inhibition and fear of pain may independently contribute to experimental pain tolerance (Oosterman et al. 2010a). It has furthermore been shown that the effects of mood on pain processing may be independent from attentional factors (Villemure and Bushnell 2009). On the contrary, catastrophizing may increase the distractive effects of pain on concurrent task performance, in both pain-free volunteers and in chronic pain patients (Crombez et al. 2002; Vancleef and Peters 2006). High catastrophizers may further have a heightened attentional focus on pain (Seminowicz and Davis 2006). In addition, depression and, to a lesser extent, anxiety and catastrophizing predict self-reported memory problems in chronic pain patients (Muñoz and Esteve 2005). Catastrophizing and coping may also be associated with memory functions as assessed with neuropsychological tests (Jorge et al. 2009). However, relationships of catastrophizing or depressive symptoms with processing speed, attention, and executive function may be less clear (Oosterman et al. 2012; Veldhuijzen et al. 2012), and, overall, not much support exists for the notion that psychological and pain cognition scores are related to cognitive test performance in chronic pain patients (see Moriarty et al. 2011, for a review).


6.7 Recommendations for Clinicians


When deciding which tools to use, several points are important to consider. Pain can be reliably assessed with measures such as the NRS, assessing pain from a unidimensional point of view, or with more generic tools assessing multiple dimensions of pain, such as the MPQ and CPG. It is advisable to assess cognitive functioning, since many patients suffering from chronic pain report cognitive problems (mostly memory and concentration) and display mild cognitive decline. When one wishes to have an extensive assessment of cognitive functioning, batteries such as the WAIS-IV (full-scale IQ), D-KEFS (executive functioning), TEA (attention), and WMS-IV (memory functioning) can be employed. For brief examinations of cognition, the NART or WAIS-IV subscales (IQ estimate), WMS-IV subtests (e.g. story recall), or word list learning paradigms such as the RAVLT, HVLT, or CVLT-II (memory functioning) and the TMT, Stroop test, or WCST (executive functioning) can be administered. Subtests of the TMT and Stroop may also be used to measure psychomotor speed and attention.

Regarding pain cognitions, catastrophizing measured with, for example, the PCS or PCL and pain beliefs measured with lists such as the PBPI or CSQ are recommended since catastrophizing behavior and pain beliefs have been repeatedly associated as important factors influencing (or even moderating) pain processing and treatment success in chronic pain patients. Lists such as the BDI-II, CES-D, STAI, and PASS are useful to measure the level of depressive symptoms and anxiety. HEXACO and NEO-PI, as well as the PPI, are suitable to measure personality traits and negative affectivity, respectively.


6.8 Summary and Conclusions


This chapter focused on interpretational and conceptual issues that should be considered in pain assessments and also provided a comprehensive overview of neuropsychological tests, pain cognitions, and emotional and personality constructs. One conclusion is that the interpretation of neuropsychological test results should be done with caution, bearing in mind that neuropsychological tests require multiple functions for intact performance. Also, emotional and personality factors are highly interrelated constructs, suggesting it is important to examine them concurrently in relation to pain assessments. Finally, it is important to keep in mind that personality and psychological constructs and affective states and traits are used interchangeably to refer to different levels of explanation.

Future studies are needed in which the diverse pain components are compared in relation to cognition, emotion, and personality. Not only does this imply a distinction between experimental indices such as pain threshold and pain tolerance levels, but it is also crucial to differentiate between sensory-discriminative, affective-motivational, and cognitive-evaluative aspects. Particularly little is known about potential differences between these latter two aspects in relation to cognitive and emotional/personality factors. It has been suggested that brain regions involved in cognitive-evaluative aspects (e.g., prefrontal cortex) are compromised in irritable bowel disease, whereas feelings of anxiety and depression may be primarily associated with diminished gray matter density in brain regions involved in processing the affective-motivational pain aspects (Seminowicz et al. 2010). Therefore, a differentiation between the medial pain aspects may be pivotal when examining associations with cognitive and emotional factors; hence, a further examination of these different pain aspects in relation to neuropsychological performance, pain cognitions, and emotional and personality constructs is warranted. The independent contributions of each factor should be investigated when possible, preferably within mediation models that concurrently integrate these distinct functions.

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Oct 21, 2016 | Posted by in PAIN MEDICINE | Comments Off on Tools That Should Be Considered in Pain Assessment: Cognitive Factors, Emotion, and Personality

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