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PART THREE  EVALUATION OF THE PAIN PATIENT

TABLE 23.2  Areas Addressed in Psychological Interviews Experience of Pain and Related Symptoms • Location and description of pain (e.g., “sharp,” “burning”) • Onset and progression • Perception of cause (e.g., trauma, virus, stress) • What has the patient been told about the symptoms and condition? Does the patient believe that this information is accurate? • Exacerbating and relieving factors (e.g., exercise, relaxation, stress, massage) • Pattern of symptoms (e.g., worse certain times of day or following activity or stress) • Sleep habits (e.g., difficulty falling to sleep or maintaining sleep, sleep hygiene) • Thoughts, feelings, and behaviors that precede, accompany, and follow fluctuations in symptoms Treatments Received and Currently Receiving • Medication (prescribed and over-the-counter). How helpful have these been? • Pattern of medication use (as needed, time-contingent), changes in quantity or schedule • Physical modalities (e.g., physical therapy). How helpful have these been? • Exercise (e.g., Do they participate in a regular exercise routine? Is there evidence of deactivation and avoidance of activity due to fear of pain or exacerbation of injury?). Has the pattern changed (increased, decreased)? • Complementary and alternative (e.g., chiropractic manipulation, relaxation training). How helpful have these been? • Which treatments have they found the most helpful? • Compliance (adherence) with recommendations of health care providers • Attitudes toward previous health care providers Compensation and Litigation • Current disability status (e.g., receiving or seeking disability, amount, percentage of former job income, expected duration of support) • Current or planned litigation Responses by Patient and Significant Others • Typical daily routine • Changes in activities and responsibilities (both voluntary and obligatory) due to symptoms • Changes in significant other’s activities and responsibilities due to patient’s symptoms • Patient’s behavior when pain increases or flares up • Significant others’ responses to behavioral expressions of pain • What does the patient do when pain is not bothering him or her (uptime activities)? • Significant other’s response when patient is active • Impact of symptoms on interpersonal, family, marital, and sexual rela-

Coping • How does the patient try to cope with his or her symptoms? Does patient view himself or herself as having any role in symptom management? If so, what role? • Current life stresses • Pleasant activities Educational and Vocational History • Level of education completed, including any special training • Work history • How long at most recent job? • How satisfied with most recent job and supervisor? • What like least about most recent job? • Would the patient like to return to most recent job? If not, what type of work would the patient like? • Current work status, including homemaking activities • Vocational and avocational plans Social History • Relationships with family or origin • History of pain or disability in family members • History of substance abuse in family members • History of or current, physical, emotional, and sexual abuse. Was the patient a witness to abuse of someone else? • Marital history and current status • Quality of current marital and family relations Alcohol and Substance Use • History and current use of prescribed psychoactive medications • Consider the CAGE questions as a quick screen for alcohol dependence. a Depending on response, consider other instruments for alcohol and substance abuse. b Psychological Dysfunction • Current psychological symptoms/diagnosis (depression including suicidal ideation, anxiety disorders, somatization, posttraumatic stress disorder). Depending on responses, consider conducting structured interview such as the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) (SCID). c • Is the patient currently receiving treatment for psychological symptoms? If yes, what treatments (e.g., psychotherapy or psychiatric medications)? How helpful are the treatments? • History of psychiatric disorders and treatment including family counseling • Family history of psychiatric disorders Concerns and Expectations • Patient concerns/fears • Explanatory models of pain held by the patient • Expectations regarding the future and treatment (will get better, worse, never change) • Attitude toward rehabilitation versus “cure” Treatment Goals • Current and history of alcohol use (quantity, frequency) • History and current use of illicit psychoactive drugs

tions (e.g., changes in desire, frequency, or enjoyment) • Activities that patient avoids because of symptoms • Activities continued despite symptoms

• Pattern of activity and pacing of activity (can use activity diaries that ask patients to record their pattern of daily activities [e.g., sitting, standing, walking] for several days or weeks)

a Adapted from Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974;131:1121–1123. b Adapted from Allen JP, Litten RZ. Screening instruments and biochemical screening tests. In: Graham A, Schultz T, Wilford BB, eds. Principles of Addiction Medicine . Chevy Chase, MD: American Society of Addiction Medicine; 1998:263–278. c Adapted from American Psychiatric Association. User’s Guide for the Structured Clinical Interview for DSM-IV Axis I: Clinician Version . Washington, DC: American Psychiatric Press; 1997.

may recommend that such a record be obtained and request urine toxicology screening to rule out aberrant opioid-taking behaviors. 83 Self-report Inventories In addition to interviews, a number of standardized assessment instruments designed to evaluate patients’ attitudes, beliefs, and expectancies about themselves, their symptoms, and the health care system have been developed and published. One survey 84

of clinicians who treated pain indicated that the five most fre- quently used instruments in the assessment of pain, in order of frequency, were the McGill Pain Questionnaire, 85,86 Beck Depression Inventory (BDI), 87,88 Multidimensional Pain Inven- tory (MPI), 89 Coping Strategies Questionnaire (CSQ), 90 and the Oswestry Low Back Pain Questionnaire. 91 Standardized instruments have advantages over semi-​struc- tured and unstructured interviews. They are easy to adminis- ter, require less time, assess a wide range of behaviors, obtain