Psychological/Psychosocial Assessment of Pain Patients

1. Psychological/PsychosocialAssessment of Pain Patients PRESENTER: Donald M. Whitley, II, Ph.D. Idaho Pain Group Bingham Memorial Hospital Blackfoot, Idaho

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

3. Psychosocial Factors • Emotions/ Present & Past state • Cultural Background • Attitudes • Beliefs • Expectations • Social and Environmental Context

4. Psychosocial Factors (cont) • Meaning of Pain to the Patient • Biological Factors • Turk & Okifuji (2002)

5. Biopsychosocial Model • Interaction between • Biological variables • Psychological variables • Sociocultural variables • That shape a patient’s response to pain. • (Turk & Okifuji, 2002)

6. Adaptive versus Maladaptive • Fear • Avoidance • Hypervigilance • Interpretation of physical sensation • (Turk & Okifuji, 1996)

7. 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)

8. 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)

9. 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)

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

11. 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)

12. Screening Instruments • Behavioral Checklist • Behavioral/Pain Assessment • Expectations Form

13. 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 CAN’T 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

14. 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 & doesn’t)

15. 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

16. Clinical Interview (Cont) • Mental Status • Mood • Affect • Thought Process issues • Hallucinations/Delusions • Paranoia • Grandiosity • Magical Thinking • Etc.

17. Clinical Interview (cont) • Mental Status (cont) • Judgment • Insight • Impulse Control • Orientation • Sleep Pattern • Concentration • Memory

18. Clinical Interview (cont) • Mental Status (cont) • Intellectual Level • Patient’s sense of their capabilities

19. Frequent comorbidities • Depression • Major Depression • Bi-Polar Disorders • Dysthmic Disorder • Mood Disorder due to General Medical Condition

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

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

22. Diagnosis • Cognitive Disorder • Dementia • Personality Disorders • Borderline • Avoidant • Dependent • Anti Social

23. 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

24. Other Disorders Factitious Disorder Adjustment Disorders Sleep Disorders

25. 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.

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

27. 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

28. Behavioral Treatments • Psychophysiologic Techniques • Relaxation Therapy • Biofeedback • Hypnosis

29. 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

30. Definitions: many words are misused • Abuse (non compliance) • Diversion (illegal) • Tolerance (normal) • Physical dependence (normal) • Pseudo-addiction (treatable) • Addiction (severe mental disease)

31. Case Study#1 • 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.

32. Case Study #1 (cont) • Referral (cont) • No Psychotherapy/counseling • Prior Psychotropic's include: Cymbalta, Abilify, Zyprexa

33. 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

34. 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