Psychology Pain Management

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Psychology Pain Management

• Jeff Baker, Ph.D.UTMB Psychology Training
  Program
• Chief Psychologist, Anesthesiology,
  Cardiothoracic Surgery, Spine Surgery, Adult
  Rehabilitation Center

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Significant Risk Factors for Chronic, Disabling
Low-Back Pain Update 2002

• Known Risk Factors
• MMPI Scale 3 Elevation
• Poor Quality of Life
• Depressed
• Low activity/high pain behaviors
• Negative beliefs/fear of pain
• Thacker, I., Hadjipavlou, A., Volk, R., Baker,
  J., and McCoy, C. (1997) Comparison of Seven
  Psychometric Instruments Used in Evaluation of
  Patients with Low Back pain. The Journal of Bone
  and Joint Surgery, Orthopaedic Proceedings,
  Supplement I, Volume 79-B.

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Important Risk Factors

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

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Patients Would like a Simple Quick Fix
It is not always that easy, but sometimes it
provides enough relief to recover.
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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)

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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
• Coping Skills Questionnaire

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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.

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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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Many Patients Want Surgery or Meds Without Much
Personal Effort
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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
• 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

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MMPI2 Case Example 2

• Patient evaluated for decompression and fusion
• No clinical pathology
• No significant elevations on MMPI
• Unemployed for 1 year
• No significant support system (occasional
  boyfriend)
• Cheerful, conversational, exhibited no pain
  behaviors
• Reports no significant psychosocial stressors or
  litigation

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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.

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MMPI2 Case Example 4

• Patient was referred for pain management
• Not considered a surgical candidate
• Elevations on 2, 6, 8, 3, 1 7 Scales
• Currently unemployed
• Pursuing litigation
• Reports Significant depression
• Reports Significant psychosocial stressors, some
  support

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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

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Quality of Life

• Work
• Avocation/Hobbies
• Family
• Spirituality
• Mobility
• Financial
• Health Care System

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McGill-Melzack Pain Questionnaire

• Pain Drawing
• Patient Self Reports where their pain is located
• Diffuse Pain More Complicated Results
• Three Scoring Methods Available (Margolis, McCoy,
  Wiltse), Margolis had .99 interrater reliability.

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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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Surgery Rating by Psychology

• 5 Excellent Candidate
• 4 Good Candidate
• 3 Moderate Candidate
• 2 Significant Concerns
• 1 Serious Psychological Concerns

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Pain Psychology Services at UTMB

• Anesthesiology Pain Clinic
• Cardiothoracic Surgery Clinic
• IBS Clinic
• Consultations (Oncology, Adult Rehab)