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Psychological Conditions Associated with Spinal Disorders

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Title: Psychological Conditions Associated with Spinal Disorders


1
Psychological Conditions Associated with Spinal
Disorders
  • Jeff Baker, Ph.D.Clinical Associate Professor
    Chief PsychologistAnesthesiology Pain
    ClinicSpine Surgery ClinicAdult Rehabilitation
    CenterCardiothoracic Surgery ClinicDirector,
    UTMB Psychology Training

2
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

3
Pains Vicious Cycle
4
Pain Disorders Psychosocial ComponentDSMIV
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.

5
Significant Risk Factors for Chronic, Disabling
Low-Back Pain Update 2001
  • Known Risk Factors
  • MMPI Scale 3 Elevation
  • Depression
  • Low activity/high pain behaviors
  • Negative beliefs/fear of pain

6
Important Risk Factors
  • Age
  • Severe Psychological stress or abuse
  • Subjective Pain Intensity
  • Substance Abuse
  • Compensation Unemployment
  • 5 Positive Waddell Signs

7
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

8
Patients Would like a Simple Quick Fix
It is not always that easy, but sometimes it
provides enough relief to recover.
9
Psychological Disorders (DSMIV) associated with
Chronic PainADJUSTMENT DISORDERS
  • 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)

10
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.

11
Psychological Assessment
  • Clinical Interview
  • Psychological Eval
  • MMPI2
  • BDI II
  • Coping Skills Questionnaire

12
Characteristics of Patients with Debilitating
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.
  • Dissatisfaction with the medical care received
    and/or anger at rehabilitation professionals.
  • Participation in doctor-shopping.
  • Analgesic or ETHO abuse.

13
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.

14
Many Patients Want Surgery or Meds Without Much
Personal Effort
15
Beck Depression Inventory (BDI)
16
Minnesota Multiphasic Personality Inventory-2
  • Developed in 1942 Renormed in 1989
  • 3 Validity Scales
  • Lies, Faking (Over reporting/Under reporting
    symptoms), K Correction

17
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

18
Clinical Use of the MMPI2 Patients with Chronic
Pain
19
MMPI2 Case Example 1
  • Evaluated for spinal fusion
  • Horse/MVA 1998
  • 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

20
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, some
    support

21
MMPI2 Case 3
  • 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.

22
MMPI2 Case Example 4
  • 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
    Wal-Mart
  • Patient has no family support

23
MMPI2 Case 5
  • 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

24
McGill-Melzack Pain Questionnaire
  • Pain Drawing
  • Patient Self Reports where their pain is located
  • Diffuse Pain More Complicated Results

25
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

26
Common Psychological Conditions Associated with
Spinal Disorders
  • Depression (Somaticized Clinical)
  • Anxiety (Situational Chronic)
  • Character Disorders (Personality)
  • Borderline
  • Hypochondriacal
  • Narcissistic
  • Schizoid

27
Psychological Techniques for working with
Patients with Chronic Pain.
  • Relaxation Training
  • Biofeedback
  • Visualization
  • Cognitive Restructuring
  • Behavioral Modification
  • Stress Management
  • Hypnosis
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