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CHAPTER 23  Multidisciplinary Assessment of Patients with Chronic Pain

patients with chronic symptoms had a distinct personality type that predisposed them to developing chronic pain—“pain-prone personality.” They specifically suggested that persistent symp- toms offered a solution for their preexisting neurosis. There has been little empirical support indicating that the majority of chronic pain patients manifest character traits comprising a common and unique disposition. 73 However, some studies have noted the high lifetime prevalence of psychiatric diagnoses ob- served in chronic pain patients, 74 and prospective studies that followed healthy individuals who subsequently develop back pain 2 and from acute injuries to the presence of disabling pain 75 have observed that premorbid psychological factors were the best predictor of persistent pain chronicity. Psychological Consequences of Chronic Pain Psychological symptoms following the onset of pain have also been thoroughly documented. Acute and long-lasting psycho- logical symptoms following symptom onset are prevalent. 76,77 Disabling emotional symptoms have been observed in as many as 59% of people following initial pain onset. 74 A number of studies have implicated the role of the patient’s idiosyncratic appraisals of his or her symptoms, expectations regarding the cause of the symptoms, and the meaning of the symptoms, in addition to organic factors, as essential in under- standing the individual’s report of pain and subsequent disabil- ity. 2,78 Moreover, the patient’s current mood, ways of coping with symptoms, and responses by significant others including physicians may modulate the experience of pain, particularly chronic or recurrent pain. 79 Failure to address these factors can result in poor response to treatments that focus exclusively on somatic causes. The results of many studies implicate psychological symp- toms as concomitants rather than precursors to chronic symp- toms after chronic pain. 80 Initial reaction to an injury, rather than the preexisting psychological status, has been shown to predict chronicity. 2,78 It seems reasonable that preexisting psy- chological status may predispose some individuals to chronic emotional disturbances following an injury. For example, acute emotional distress has been shown to be related to pain sever- ity 1 month following a motor vehicle collision. 81 The correct answer is probably somewhere in the middle where preexist- ing psychological disturbances, immediate emotional reaction, coupled with medical complications contribute to chronicity of pain, at least for some people. In either case, these studies underscore the importance of evaluating psychological factors for all chronic pain patients. ELEMENTS OF THE PSYCHOLOGICAL EVALUATION Table 23.1 contains a brief set of salient issues with the acronym ACT-UP (Activity, Coping, Think, Upset, People’s responses) that can be used as a guide for interviewing patients who report persistent or recurring symptoms. Generally, a referral for eval- uation may be indicated where disability greatly exceeds what would be expected based on physical findings alone, when pa- tients make excessive demands on the health care system, when the patient persists in seeking medical tests and treatments when these are not indicated, when patients display significant TABLE 23.1  Brief Psychosocial Screening: ACT-UP Activities : How is your pain affecting your life (i.e., sleep, appetite, physical activities, relationships)? Coping : How do you deal/cope with your pain (what makes it better/ worse)? Think : Do you think your pain will ever get better? Upset : Have you been feeling worried (anxious)/depressed (down, blue)? People : How do people respond when you have pain?

emotional distress (e.g., depression or anxiety), or when the patient displays evidence of addictive behaviors or continual nonadherence to the prescribed regimen. Table 23.2 contains a detailed outline of the areas that should be addressed in a more extensive psychological interview for pain patients. Interviews A psychological interview with chronic pain patients is typically semi-structured. A structured format of psychiatric interview 82 can be incorporated as a tool to examine psychopathology. However, a psychological interview with pain patients’ needs to go beyond an assessment of psychopathology because its main purpose is to assess a wide range of psychosocial factors (not just psychopathology) related to a patient’s symptoms and disability. When conducting an interview with chronic pain patients, the health care professional should focus not only on gather- ing information provided by the patient but also on observing patients’ pain behaviors and the manner in which they convey information (e.g., facial expressions, movement patterns). We discuss some specific measures that have been proposed to sys- tematically assess pain behaviors later. Chronic pain patients’ beliefs about the cause of symptoms, their trajectory, and beneficial treatments will have important influences on emotional adjustment and adherence to therapeu- tic interventions. A habitual pattern of maladaptive thoughts may contribute to a sense of hopelessness, dysphoria, and un- willingness to engage in activity. These reactions, in turn, de- activate the patient and severely limit his or her physical and emotional adaptation. The interviewer should also determine both the patient’s and the significant other’s expectancies and goals for treatment. An expectation that pain will be eliminated completely may be unrealistic and will have to be addressed to prevent discouragement when this outcome does not occur. Setting appropriate and realistic goals is an important process in pain rehabilitation as it requires the patient to attain better understanding of chronic pain and goes beyond the dualistic, traditional medical model—somatogenic versus psychogenic. In order to help chronic pain patients understand the psy- chosocial aspects of pain, attention should focus on the pa- tients’ reports of specific thoughts, behaviors, emotions, and physiologic responses that precede, accompany, and follow pain episodes or exacerbation as well as the environmental conditions and consequences associated with their responses in these situations. During the interview, the clinician should attend to the temporal association of these cognitive, affective, and behavioral events; their specificity versus generality across situations; and the frequency of their occurrence to establish salient features of the target situations, including the con- trolling variables. The interviewer should seek information that will assist in the development of potential alternate responses, appropriate goals for the patient, and possible reinforcers for these alternatives. Patients with chronic pain problems typically consume a va- riety of medications to alleviate their symptoms. It is important to discuss a patient’s medications during the interview, as many pain medications (particularly opioids) are associated with side effects that may mimic emotional distress and can have delete- rious adverse effects. A clinician, for example, should be famil- iar with side effects that result in fatigue, sleep difficulties, and mood changes to avoid misdiagnosis of depression. A general understanding of commonly used medications for chronic pain is important, as some patients also may use opioid analgesics to manage dysphoric mood that accompanies pain and its im- pact. During the interview, potential psychological dependence and aberrant drug-seeking behaviors on pain-relieving medi- cations should be evaluated. In the majority of states in the United States, a physician is able to obtain a record of prescrip- tions of controlled substances. When in doubt, a psychologist