Psychological Evaluation of the Patient in Pain

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					Psychological Evaluation of the
      Patient in Pain

     Alfredo Romero, MD
              General Topics
• It’s considered a standard protocol in many
  pain centers
• In most chronic pain syndromes some
  mixture of psychological and
  pathophysiologic influences is found
• Avoid diagnostic labels such as hysterical,
  hypochondrical, and functional
• It is very important to state that the
  referral is not because pain is psychogenic
  or not real, but because evaluation can
  provide useful information about factors
  that might be increasing suffering and
  functional disability.
• Delay in psychological referral and
  treatment, place the patient at high risk for
     Indication for Psychological
• Affected patient’s ability to engage in
  normal activities
• Affected interpersonal relationships
• Patient shows signs of significant
  psychological distress (e.g depression,
• Patient repeatedly and excessively uses
  the health care system
• Patient persists in seeking invasive
  investigations or treatments after being
  informed these are not appropriated
• Inappropriate use of opioid, sedative-
  hypnotic medications or alcohol
     Purposes of a Psychological

• The primary goal is to identify emotional
  and behavioral factors that may be
  complicating or perpetuating the clinical
  pain presentation.
• Reveal aspect of the patient’s psychosocial
  history that are relevant to the current
• Define psychological and behavioral
  treatment strategies
          Personality Disorders
• Definition: An enduring pattern of inner
  experience and behavior that deviates
  markedly from the expectations of the
  individual’s culture, is pervasive and
  inflexible, has an onset in adolescence or
  early adulthood
• Kinney et al found that 60% of their sample
  of chronic patients met de diagnosis of
  personality disorders.
• Those disorder are particularly influential in
  a patient’s response to pain management
  and rehabilitation
The Dependent, Avoidant, Fearful
• Evidence of clinical anxiety and
  nervousness, including hypervigilance,
  motor tension, pressured speech, and
• Excessive dependence on physicians for
  continued guidance and support.
• Tendencies toward obsessive-compulsive
  behaviors such us persistent focus on
  diagnostic test results or medications
• Unfounded resistance to the use of
• These persons may be more open to
  acknowledging the role of psychological
  influences in their pain.
    The Dramatic, Borderline,
      or Histrionic Patient
• Few or no objective findings to explain
• Often a female with a long history of
  problems with relationships
• Overly dramatic and excitable, labile
• Possible attention-seeking behaviors such
  as exaggerated statements of pain or other
  physical problems
• Tendencies to demonstrate helplessness
• Tendencies toward numerous phone call to
  the physician, personal crises, and negative
  responses to treatment or interventions
    The Antisocial/Sociopathic
• Usually little objective organic evidence for
• Probable history of multiple injuries or
• History of violent or aggressive behavior
• History of “doctor shopping” or demands
  for changing physicians
• Frequent negative comments about prior
  treatment, physicians or case managers
• History of substance abuse, problems with
  legal system
• History of family problems
• Indirect or direct evidence of a history of
      The Somatoform Disorders
• Up to 75% of all visits to PCP involve
  manifestations of psychosocial problems in
  physical complaints
• The primary feature is the presence of
  physical symptoms that suggest a medical
  condition that cannot be fully explained by
  organic findings or known physiologic
• There is usually evidence of a significant
  psychological component
• The production of physical symptoms and
  complaints is not a conscious and
  intentional act on the part of the patient
        Somatoform Disorders

• Somatization Disorder
 Report recurrent and multiple somatic
  complaints for which medical attention has
  been sought.
 Symptoms have no clear relationship to
  any physical or medical disease
 Typically there is a combination of pain, GI
  symptoms, sexual dysfunction, and vague
  neurologic complaints
 Anxiety and affective symptoms are
  associated features
          Somatoform Disorders
     Conversion Disorder
•   Patients present with neurologic or other
    medical symptoms that suggest or reveal
    deficits in voluntary motor or sensory
•   Symptoms are considered an expression of
    psychological conflict or need.
•   Symptoms typically develop during times of
    particular psychological stress.
•   Conversion disorder is not diagnosed when
    conversion symptoms are limited to pain.
•   Most common symptoms are seizures,
    paralysis, coordination disturbance,
    blindness, and paresthesias.
        Somatoform Disorders
Pain Disorder
• Preoccupation with pain in the absence of
  physical findings that fully account for a
  cause or intensity of the pain.
• Pain is inconsistent with an anatomic
• Psychological factors are judge to play a
  significant role in pain
• Patients often refuse to seriously consider
  that psychological factors might be
  influencing the clinical picture
• Symptoms of depression are common.
      Factitious Disorders and
• Factitious disorders
 Are physical or psychological symptoms that
  intentionally produced or feigned.
 External incentives for assuming a sick role,
  such as economic gain, work avoidance, or
  evading legal responsibility, are absent
• Malingering
 Intentional presentation of physical or
  psychological symptoms motivated by
  external incentives.
 Malingering is not considered a mental
 Should be suspected I there is a
          Affective Disorders
• Depression is the most common emotional
  disorder among patients with chronic pain
• Depression may occur as a reaction to pain
  or antedates the onset of pain.
• Can actually increase analgesic
• Ask about suicidal ideas or specific plan to
  commit suicide
• A vicious cycle of pain, depression, and
  insomnia can develop, and patients often
  mistake emotional distress for pain.
• History and current subjective experience
  of the pain
• Conceptualization of the pain problem and
  treatment expectations
• Previous and current treatment and
• Behavioral analysis
• Vocational assessment and compensation
  and litigation status
• Social history
• Recent life stress
• Alcohol and substance abuse
• Assessment of psychological dysfunction.
  Comprehensive Assessment
• Minnesota Multiphasic Personality Inventory
 Most widely instrument used in
  psychological assessment.
 Depressive symptoms have been identified
  in association with increased pain
 Intensity of depression has been found to
  be a significant negative predictor of
  treatment outcome.
 Patients with high score on somatization
  have had higher scores on pain-related
    Comprehensive Assessment

• The Battery for Health Improvement (BHI)
 It is a self-report inventory to identify
  factors that interfere with a patient’s
  normal course of recovery from a physical
 The test is helpful for workers’
  compensation patients because it gathers
  information about patient’s readiness for
  vocational training or job placement
 It is also helpful for evaluating emotional
  readiness for surgery
  Comprehensive Assessment
• Pain Patient Profile (P-3)
  Effective instrument for briefly
  assessing for personality and psychological
  characteristics that are known to affect
  pain perception and treatment response of
  patients in pain
   A computerized profile is produced with
  an interpretation that compares the pain
  patient to a national sample of patients in
   Symptoms of depression and
  somatization were significant predictors of
  medical and psychological factors that
  affected treatment outcome.

Psychological assessment of the
patient pain should include
multidimensional evaluation and
measures of compliance, motivation
factors, and the social influences of
pain on the patient

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