Evaluation of Patients with Chronic Pain

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Evaluation of Patients with Chronic Pain

• The University of Texas Medical Branch at
  Galveston

• Jeff Baker, Ph.D.
• Clinical Associate Professor Chief Psychologist
• Anesthesiology Pain Clinic Orthopaedics
  Rehabilitation

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Pain Memory

• Pain--has an Element of Blank--
• It cannot recollect
• When it begun--0r if there were
• A time when it was not
• Emily Dickinson

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Pain Disorders - Psychosocial Component DSMIV
Classification System

• Pain Disorder Associated with psychological
  factors (307.80)
• Pain Disorder with both psychological factors and
  a general medical condition (307.89)
• Psychological Distress
• Disturbed Sleep
• Sad, agitated affect
• Residual effects are as difficult on the family
  as it is on the individual
• Urge to do something--anything--to stop the pain
  and get back to what was their previous level
  of functioning
• Become drug seekers, manipulators, etc.

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Risk Factors for Chronic, Disabling Low-Back
Pain Update 2000

• Known Risk Factors
• MMPI Scale 3 Elevation
• Depression
• Low activity/high pain behaviors
• Negative beliefs/fear of pain

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Additional Risk Factors

• Age
• Severe Psychological stress or abuse
• Subjective Pain Intensity
• Substance Abuse
• Compensation Unemployment
• 5 Positive Waddell Signs

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Chronic Pain is the most costly health problem in
America

• Cancer pain - 800,000 new cases per year, 430,000
  people die
• Headache - 40 million, 4 billion
• Arthritis pain - 20 million, 4 billion
• Low Back pain - 2 million, 5 billion

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Patients Would like a Quick Fix
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Adjustment Disorders (DSMIV) associated with
Chronic Pain

• With Depressed Mood (309.0)
• With Anxiety (309.24)
• With mixed anxiety and depression (309.28)
• With disturbance of Conduct (309.3)
• With mixed disturbance of emotions and conduct
  (309.4)
• Adjustment Disorder Unspecified
• Low back pain (724.2)

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Psychological Assessment Patients with Chronic
Pain

• Clinical Interpretation varies based upon
  psychosocial factors and validity scales.
• Assists the patient with understanding
  psychological component of pain.
• Objective measures assist in identifying the
  extent of possible severe psychopathology.
• Assists surgeons and anesthesiologists in a
  better understanding of psychological dynamics of
  patients with chronic pain.

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Psychological Assessment

• Clinical Interview
• Psychological Eval
• MMPI2
• BDI II
• CSQ
• QOL

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Patient Characteristics of Chronic Pain

• Constant or recurrent pain present beyond the
  normal healing period.
• Complaints and response to pain disproportionate
  to objective findings.
• Signs of symptom magnification on objective
  physical, functional, and psychological
  evaluation (present in 50 of patients).
• No response or short period of response to
  traditional treatment (conservative measures or
  surgery).
• Reduction in work and physical and recreational
  activities.
• Significant depression, with anxiety, increased
  irritability, and poor interpersonal
  relationships.
• Dissatisfication with the medical care received
  and/or anger at rehabilitation professionals.
• Participation in doctor-shopping.
• Analgesic or ETHO abuse.

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Many Patients Want Surgery or Meds Without Much
Personal Effort
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Characteristics of Chronic Pain Continued

• Preoccupation with finding a cure for pain and
  rejection of the idea that they may have to live
  with physical difficulties.
• Denial of any possible relationship to
  psychological issues.
• Refusal to allow regimens involving patient
  effort.
• Pursuit of disability claims and litigation.

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Beck Depression Inventory (BDI)
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Minnesota Multiphasic Personality Inventory-2

• Developed in 1942 Renormed in 1989
• 3 Validity Scales
• Lies, Faking (Over reporting/Under reporting
  symptoms), K Correction

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Clinical Scales of the MMPI2

• Scale 1 - Hypochondriasis
• Scale 2 - Depression
• Scale 3 - Conversion Hysteria
• Scale 4 - Psychopathic Deviate
• Scale 5 - Masculinity/Femininity
• Scale 6 - Paranoia
• Scale 7 - Psychasthenia
• Scale 8 - Schizophrenia
• Scale 9 - Hypomania
• Scale 10 - Social Introversion

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Clinical Use of the MMPI2 Patients with Chronic
Pain
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MMPI2 Case Example 1

• Evaluated for spinal fusion
• Secretary, Sales Clerk, Horse Trainer
• Physical Assault 1988
• MVA 1991
• Cannot sit, stand, or walk for extended periods
• Elevated 1 3 Scales
• Pt has 6 month history of low back pain
• Not currently employed, wants to go back to work
• Financial stressors
• Positive family support

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MMPI2 Case Example 2

• Patient evaluated for spinal fusion
• Mild pathology
• Elevations on 4 2 Scales
• Currently unemployed
• Pursuing litigation
• Reports Significant depression
• Reports Significant psychosocial stressors

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MMPI2 Case Example 3

• Patient evaluated for chronic back pain
  symptoms do not match organic
• Severe clinical pathology
• Elevations of 2, 1, 3, 7, 8 Scales
• Patient has serious psychosocial stressors
  including major depression
• Patient has no source of income
• Patient is currently in litigation against
  WalMart
• Patient has no family support

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MMPI2 Case 4

• Patient evaluated for 3 level fusion
• Serious psychopathology
• Pt has hx of serious mental illness
• Elevations on 8, 6, 2, 4, 7, 3, 0, 1 Scales
• Pt has difficulty with reality based decisions

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MMPI2 Case 5

• Patient evaluated for fusion
• Patient has major elevation on 6 scale
• Slight elevations on 1 3 scales
• Ex Policeman fired after 8 years
• Recently Divorced
• Diagnosed w/OCPD
• 1st Time in indigent care system
• Patient fired his last M.D.

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McGill-Melzack Pain Questionnaire
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Waddell Signs

• Nonorganic Physical Signs in Low-Back Pain
• Tenderness
• Not localized
• Simulation Tests
• Pain Happens with simulated test
• Distraction Tests
• Straight Leg Raise
• Regional Disturbances
• Neighboring parts
• Overreaction
• Hypochondriacal qualities

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Common Psychological Conditions Associated with
Spinal Disorders

• Depression (Somatized Clinical)
• Anxiety (Situational Chronic)
• Character Disorders (Personality)
• Borderline
• Hypochodriacal
• Narcissistic
• Schizoid

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Psychological Techniques for working with
Patients with Chronic Pain.

• Relaxation Training
• Biofeedback
• Visualization
• Cognitive Restructuring
• Behavioral Modification
• Stress Management
• Hypnosis

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Outcome Measures

• Reduction in Pain vs. Physical Function
• Quality of Life Health Aspects
• Functional Capacity
• Ability to Return to Work

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Clinical Use of Quality of Life Enjoyment
Satisfaction Questionnaire

• Physical Health
• Subjective Feelings
• Work
• Household
• School/Courses
• Leisure Time Activities
• Social Relationships
• General

• Assists understanding of Big Picture
• Assists patient to better understand quality of
  life and enjoyment
• Assists patient to set new goals for treatment