PsychologicalPsychosocial Assessment of Pain Patients

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Psychological/PsychosocialAssessment of Pain
Patients

• PRESENTER
• Donald M. Whitley, II, Ph.D.
• Idaho Pain Group
• Bingham Memorial Hospital
• Blackfoot, Idaho

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Pain

• Fear of Pain and what we do about it is more
  disabling than the pain itself (Waddell et al.,
  1993)

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Psychosocial Factors

• Emotions/ Present Past state
• Cultural Background
• Attitudes
• Beliefs
• Expectations
• Social and Environmental Context

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Psychosocial Factors (cont)

• Meaning of Pain to the Patient
• Biological Factors
• Turk Okifuji (2002)

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Biopsychosocial Model

• Interaction between
• Biological variables
• Psychological variables
• Sociocultural variables
• That shape a patients response to pain.
• (Turk Okifuji, 2002)

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Adaptive versus Maladaptive

• Fear
• Avoidance
• Hypervigilance
• Interpretation of physical sensation
• (Turk Okifuji, 1996)

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Maladaptive behaviors

• Catastrophizing
• A cognitive and emotional process that involves
  magnification of pain-related stimuli, feelings
  of helplessness, and a negative orientation to
  pain and life circumstances
• (Edwards Bingham, 2006)

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Maladaptive (cont)

• Belief that persistent pain signals ongoing
  tissue damage.
• Belief that if a cause of pain can be found a
  treatment will fix it.
• Belief that pain is a signal to stop activities
  and movement.
• (Pujol, Katz, Zacharoff, 2007)

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Psychological Evaluation

• Personality Assessment Screener (PAS)
• Personality Assessment Inventory (PAI)
• Pain Patient Profile (P-3)
• Millon Behavioral Medicine Diagnostic (MBMD)
• Battery of Health Improvement 2 (BHI-2)
• Brief Battery of Health Improvement 2 (BBHI-2)

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Psychological Evaluations

• Brief Symptom Inventory 18 (BSI 18)
• Minnesota Multiphasic Personality Inventory 2
  (MMPI-2)
• Validity Indicator Profile (VIP)
• Paulhus Deception Scales

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Screening Instruments

• Screener and Opioid Assessment for Patients with
  Pain (SOAPP) 5, 14, 24
• SOAPP-R
• Drug Abuse Screening Test (DAST)
• Alcohol Use Disorder Identification Test (AUDIT)
• Current Opioid Misuse Measure (COMM)

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Screening Instruments

• Behavioral Checklist
• Behavioral/Pain Assessment
• Expectations Form

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EXPECTATIONS

• To avoid misunderstandings and disappointments,
  it is very important that you and your treatment
  team know what to expect of each other.
• 1 WHAT DO YOU EXPECT FROM OUR TREATMENT?
• WHAT CANT YOU DO NOW THAT YOU WOULD LIKE TO DO
  AGAIN?
• WHAT BOTHERS YOU THE MOST?
• ANY OTHER COMMENT
• 2 WHAT YOU CAN EXPECT FROM US
• The Idaho Pain Group is a multidisciplinary team
  and you will interact with one or more members of
  the team (Pain specialist, Psychologist,
  Physician Assistant, Nurses, Consultants).
• We may ask you to meet with the whole team to
  discuss your case.
• WE WILL WORK HARD FOR YOU AS A TEAM TO ADDRESS
  ALL THE ISSUES THAT BOTHER YOU
• WE WILL DO ONLY WHAT IS SAFE AND NECESSARY
• WE WILL NOT BE ABLE TO ELIMINATE ALL PAIN BUT
  .
• OUR GOAL IS TO GET YOU MORE ACTIVE, DOING THINGS
  THAT YOU ENJOY
• 3 WHAT WE EXPECT FROM YOU
• BE PATIENT, THIS WILL TAKE TIME AND MANY SMALL
  STEPS
• FOLLOW THE RULES SPELLED OUT IN THE TREATMENT
  AGREEMENT (PLEASE READ THAT AGREEMENT CAREFULLY)
• FOLLOW THE TREATMENT PLAN AND PRESCRIPTIONS
  EXACTLY AS WRITTEN
• SEVERAL PEOPLE WILL BE INVOLVED IN YOUR CARE,
  THEY ARE ALL EQUALLY IMPORTANT AND NO PART OF THE
  PLAN IS OPTIONAL

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Clinical Interview

• Short time only
• Questionaires completed prior
• Focus to pain initially (Relationship)
• Etiology History
• Treatments
• PT, Medication, Surgeries, Injections,
  Chiropractic,
• Implants, etc.
  
  
  
• Treatment effects (what works doesnt)

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Clinical Interview (cont)

• Other Physical Health Problems
• Mental Health Issues
• Prior Mental Health Treatment
• Present Functioning Status (Daily Routine)
• Past History (Family of Origin), Education,
• Marital History, Present Living Situation, Work
  History
• Legal Issues
• Substance Abuse History

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Clinical Interview (Cont)

• Mental Status
• Mood
• Affect
• Thought Process issues
• Hallucinations/Delusions
• Paranoia
• Grandiosity
• Magical Thinking
• Etc.

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Clinical Interview (cont)

• Mental Status (cont)
• Judgment
• Insight
• Impulse Control
• Orientation
• Sleep Pattern
• Concentration
• Memory

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Clinical Interview (cont)

• Mental Status (cont)
• Intellectual Level
• Patients sense of their capabilities

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Frequent comorbidities

• Depression
• Major Depression
• Bi-Polar Disorders
• Dysthmic Disorder
• Mood Disorder due to General Medical Condition

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Depression

• Associated with Decreased pain tolerance
• Withdrawal
• Mood disturbance
• Frustration
• Cognitive Impairment
• Reduction in abilities
• (Innes, 2005)

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Diagnosis

• Anxiety
• Panic Disorders
• Generalized Anxiety Disorder
• Post Traumatic Stress Disorder
• Obsessive Compulsive Disorder
• Social Phobia
• Anxiety Disorder Due to General Medical Condition

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Diagnosis

• Cognitive Disorder
• Dementia
• Personality Disorders
• Borderline
• Avoidant
• Dependent
• Anti Social

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Somatoform Disorders

• Pain Disorder Associated with both Psychological
  and Medical Factors
• Pain Disorder Associated with Psychological
  Factors
• Hypochondriasis
• Body Dysmorphic Disorder
• Somatization Disorder
• Conversion Disorder

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Other Disorders

• Factitious Disorder
• Adjustment Disorders
• Sleep Disorders

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Malingering

• The intentional production of false or grossly
  exaggerated physical or psychological symptoms,
  motivated by external incentives such as avoiding
  military duty, avoiding work, obtaining financial
  compensation, evading criminal prosecution, etc.

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Malingering (cont)

• Possible assessment tools
• Structured Interview of Reported Symptoms
• Test of Memory Malingering
• Validity Indicator Profile (VIP)

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Suicide

• Suicidal Ideation is rather common in Patients
  with Chronic Pain
• The risk of death by suicide is estimated to be
  double for patients with chronic pain compared
  with controls.Tang, Psychol Med 2006.
• Anhedonia

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Behavioral Treatments

• Psychophysiologic Techniques
• Relaxation Therapy
• Biofeedback
• Hypnosis

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Behavioral Treatment

• Psychotherapies
• Exposure Based Counterconditioning
• Cognitive Behavioral Therapy
• Focus and change reaction to painful sensations
• Decrease negative emotional responses
• Increase functioning
• Usually short term 6 to 18 weeks
• Patient success related to being actively involved

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Definitions many words are misused

• Abuse (non compliance)
• Diversion (illegal)
• Tolerance (normal)
• Physical dependence (normal)
• Pseudo-addiction (treatable)
• Addiction (severe mental disease)

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Case Study1

• 49 y/o Unemployed Caucasian Male
• Referring M.D. (internal medicine)
• Panic attacks
• Lorazepam (up to 16mg p/d) Presently 2-4
• Hx low back pain radiating to legs with weakness
  and numbness (MRI confirmed failure of disc and
  stenosis)
• Percocet 6 per day, prior - muscle relaxers, PT,
  anti-inflammatories, spinal injections.

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Case Study 1 (cont)

• Referral (cont)
• No Psychotherapy/counseling
• Prior Psychotropic's include Cymbalta, Abilify,
  Zyprexa

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Case Study 1 (cont)

• Background
• Father deceased Heart Attack 50y/o
• Pt. unemployed except for occasional seasonal
  work 4-5 years
• In second marriage, Spouse providing income
• Sleeps intermittent, stays up most nights to
  early AM, same pattern for over a year
• Weight loss, not hungry
• Not active, socially isolated, extreme lethargy

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Case Study 1 (cont)

• Testing
• Anxiety Depression
• MBMD IA, FD, PS, FP, AD, PR
• No self harm indications
• High degree of focus to health issues