RENEW OR SUBSCRIBE TO PPM
Subscription is FREE for qualified healthcare professionals in the US.
11 Articles in Volume 14, Issue #1
The WHO Pain Ladder: Do We Need Another Step?
History of Pain: The Psychosocial Assessment of Pain
Lyme Disease: A Short Primer for Pain Practitioners
Opioid Prescribing Part 1: A Practical Guide to Appropriate Documentation
Pain, Impairment, Whiplash, and the New AMA Guides: What Clinicians Need to Know
The 5 Coping Skills Every Chronic Pain Patient Needs
Demystifying Benzodiazepine Urine Drug Screen Results
Practical Pain Management: The Nation’s Premier Teaching Journal for Pain Practitioners
PPM’s Editorial Board Weighs In on WHO Ladder
Are patients taking acetaminophen (Tylenol) at risk for developing serious skin conditions?
What are some home exercises and tips to help patients manage rotator cuff injuries and pain?

History of Pain: The Psychosocial Assessment of Pain

“Believe that life is worth living and your belief will help create the fact.” —William James Father of American Psychology

Over the past 30 years, we have seen tremendous changes in the diagnosis and treatment of pain—including a better understanding of pain as the 5th vital sign. The prevalence of pain is striking. According to the Institute of Medicine’s survey, an estimated 100 million people in the US experience pain.1 Further, 25% of adult Americans report having an episode of pain during the last month that persisted for more than 1 day.2

Data from the National Health Survey indicated that within the sample, 15% of adults had experienced migraines or severe headache, 15% experienced pain in the neck, 27% in the lower back, and 4% in the jaw.3

According to a recent article by Turk and Melzack, despite improvements in medicine, “pain is not well understood and the severity of the pain may not be adequately managed.”4 They further note that the central problem in providing appropriate treatment of pain continues to be the inherent subjectivity of the pain experience.

In this installment of the History of Pain, we will examine the psychosocial assessment of pain. In the August issue of Practical Pain Management, I introduced the Melzack and Casey model of pain that was published in 1968.5 I still refer to this model today to formulate my assessment approaches. As noted in earlier installments of this series, I use subjective data in forming my clinical impressions and treatment recommendations.6-8

However, health care providers should keep in mind that the assessment process is a 2-way experience because the patient also is assessing the provider based on subjective impressions. If the patient is unhappy with their provider or treatment, it can influence treatment outcome. Both the provider and the patient should keep in mind that pain medicine is not an exact science but is based on a trial and error process.

First Step: Initial Evaluation (Impressions)

The first step in the subjective assessment process begins when the patient arrives for the initial appointment. For example, the completeness of the patient’s initial paperwork, his or her appearance, and how he or she interacts with the provider’s staff create an initial impression that follows the patient throughout the assessment experience. Under usual circumstances, the patient then is evaluated by the primary care provider (PCP), who will have reviewed their initial paperwork and incorporate staff subjective impressions before actually meeting the patient.

After the PCP completes the initial evaluation of the History and Physical (H&P), 2 approaches are possible: treat the patient with pain medicine and conservative treatment (physical therapy) or refer the patient to a specialist for further assessment and recommendations. If the PCP chooses to refer to a specialist, the PCP will forward the initial evaluation that will include subjective impressions.

The specialist may elect to perform additional tests before they forward their response back to the PCP. This evaluation may include additional subjective impressions as well as objective findings. The end result is that as the patient’s medical record expands, it includes accumulating subjective impressions that will greatly influence subsequent treatment recommendations. Each participant in the assessment process plays a specific role. In addition, each provider will determine the outcome of initial assessment recommendations.

At this point in the process, the assessment and initial recommendations become part of the trial and error treatment journey. The patient should be aware that the provider is charting the course of this journey with some of the following goals: formulating a differential diagnosis, understanding the nature of the patient’s pain, evaluating the impact of the pain on the patient’s life, assessing physical strengths and weaknesses, and measuring response to treatment. Finally, the provider should be sensitive to the physical and emotional demands placed on the patient by extended assessments.

How to Measure Pain

The measurement of pain presents a number of challenges. The patient is the only one who can provide information about the intensity of their pain. Throughout the assessment process, patients are asked to rate their pain—usually using a visual analog scale (VAS) from 0-10, ranging from no pain (0) to the worst pain they can imagine (10). In reality, this may be the only measure of pain used in the clinical setting.

There are a number of concerns with this approach. For example, if a patient is asked to recall their pain level over the past week as an indication of pain intensity, the unreliable nature of memory becomes evident. One study found that patients will consistently underestimate or overestimate their pain levels when asked to recall pain.9 Therefore, relying on a single measure of pain intensity (eg, VAS), the provider is omitting critical data that maybe obtained through other assessment tools. In my practice, I use the patient’s VAS rating as a projective measure of psychosocial distress and not a sole measure of sensory perception. The old adage that you cannot tell a book by its cover is relevant to this issue.

Physical Pathology May Not Equate to Pain

There are some clinicians who feel that the only approach to identify the true nature of pain is to demonstrate physical or chemical pathology. For disability claims, including Social Security, only physical findings—imaging and laboratory results—are used to determine whether a claim should be accepted or rejected. The reasoning behind this approach is based on the faulty assumption that physical findings are directly related to the pain experience.

Unfortunately, biomedical research has not been able to confirm that the existence of physical pathology and pain are directly related. In fact, a number of studies have found that significant pathology can exist in individuals who report little or no pain, and conversely, studies have found significant levels of pain with little or no physical pathology.10-12 Turk and Melzack have written that “the association between physical abnormalities and patient’s reports of pain is often ambiguous or weak. In addition, physical pathology has been reported not to be predictive of disability.”5

Despite these findings, there are still many clinicians who feel that if pain is not associated with physical pathology, then by simple deduction, pain must be psychogenic in origin. Again, as I have pointed out previously, there is no creditable empirical research to support this position.

Important Caveats

Before I introduce specific assessment approaches and techniques, a number of important caveats should be noted. Most of what we know today about the chronic pain experience is based on a very small and select sample of the overall pain population. Our knowledge base primarily is derived from patients who have been referred to specialized pain programs and not the general population of patients who experience chronic pain.13 In addition, only a small select sample of pain patients will undergo a comprehensive psychosocial assessment. The role of a pain psychologist is very limited due to a number of factors: few psychologists specialize in pain, insurance limitations are growing, and patients are reluctant to undergo a comprehensive psychosocial evaluation. In addition, the majority of pain psychologists usually are employed by comprehensive pain management programs, which are usually located in metropolitan areas. In 1989, I was recruited by Oregon Health & Science University (OHSU) to help establish a multidisciplinary pain program. At the time, there were only 2 pain psychologists in the entire Portland area. The numbers are improving, but many pain patients will never undergo a comprehensive psychosocial evaluation. With this caution in mind, I will attempt to focus on practical assessment approaches that are relevant in today’s clinical setting.

 

Assessment Approaches

I would now like to introduce my personal approach to assessment that has evolved over 25 years of practice as a pain psychologist. Since no universally accepted template exists to guide a clinical pain assessment, I would briefly like to introduce the Initiative on Methods and Measurement and Pain Assessment in Clinical Trials (IMMPACT).14 Even though IMMPACT was proposed for research in clinical trials, 8 consensus recommendations have been published that support its use in clinical practice.15 The 4 domains and measures recommended by the IMMPACT study are shown in Table 1.

During the assessment process, I introduce a model of behavior that can be traced back to Harvard behaviorist B.F. Skinner, one of the early pioneers in operant theory. Operant theory proposes that pain behaviors are controlled by consequences, which formed the treatment approach at the University of Washington. Skinner called his model the ABCs of behavior (Figure).16 This model can apply to pain behavior since pain behaviors can be reciprocal. In other words, a consequence can act as a trigger that sets up another ABC sequence. Once the patient becomes familiar with this approach, I will ask the patient to diagram an ABC sequence from their perspective. This experience is valuable for me as a provider in assessing pain behaviors under operant control, and for the patient, since he or she is now an integral participant in the assessment process.

 

Behavioral Analysis of Pain

In 1989, I was fortunate to attend a week-long intensive workshop conducted by Wilbur “Bill” Fordyce. Dr. Fordyce was a pioneer pain psychologist, who helped found the pain management program at the University of Washington.17 For me, the most important aspect of the Fordyce workshop was his Behavioral Analysis of Pain (BAP) model. To my knowledge, he never published the BAP, so I will summarize it for the reader. For Dr. Fordyce, the main purpose of a psychological evaluation was to determine if pain/suffering behaviors appear to be controlled by social or emotional contingencies or by stimulus control as a consequence of superstitious learning. He felt strongly that the spouse or significant other also should be interviewed. I use the BAP to complement the ABC model, since you are looking for associations between pain behaviors and environmental cues (triggers) and consequences.

Dr. Fordyce recommended that the BAP should be complemented by a medical evaluation, a complete pre/post-morbid history, and psychometric testing—when indicated. There are 19 questions included in the full BAP (Table 2). If the patient appears to have a comorbid sleep problem, I will supplement the BAP with a sleep log that the patient fills out over the course of a week. I would refer the reader to a recent article I published in Practical Pain Management on sleep and pain.18

 

 

Psychometric Instruments

It now is accepted that the pain experience is a multidimensional phenomenon that requires assessing psychosocial factors that influence the sensory aspect of pain. Over the past 20 years, psychosocial assessment has been expanded with the introduction of a wide variety of psychometric instruments. It is beyond the scope of this article to review every psychometric test on the market today, so I have focused on instruments that have stood the test of time as well as more recent tests that show promise and address a newly recognized aspect of the pain experience.

 

McGill Pain Questionnaire

The first psychometric test that I am going to review is the McGill Pain Questionnaire (MPQ), which is based on the Melzack & Casey Model of Pain. The initial research was conducted by Melzack and Torgerson in 1971 to assess the 3 major components of the pain experience: sensory-discrimination, motivational-affective, and cognitive-evaluative.19 The MPQ is based on 102 descriptive adjectives that describe different aspects of the pain experience. These 102 adjectives are categorized into 3 major classes and 16 subclasses: sensory, affective, and evaluative. The MPQ further attempts to determine pain intensities implied by the adjectives within each subclass. Based on a number of studies, the MPQ appears to be valid, reliable, consistent, useful and does not take considerable time to complete.20 Since its introduction in 1975, the MPQ has been used in more than 500 research studies and has been translated into more than 18 languages. 

Sickness Impact Profile (SIP)

To assess a broad comprehensive health inventory, I use the Sickness Impact Profile (SIP). This test is included in my original battery, and I feel it has value for assessing pain and psychosocial aspects in a general medical population. The most recent version appeared in 1981, and according to the authors, it was developed to measure the impact of disease on both physical and emotional functioning.21 It is a straightforward instrument composed of 136 yes/no questions. The main scales assess ambulation, mobility, body care, movement, social interaction, alertness, behavior, emotional behavior, and communication. It also includes independent scales for sleep, rest, eating, work management, recreation, and pastimes. Published psychometric data suggest good reliability and validity.

West Haven-Yale Multidimensional Pain Inventory (MPI)

Another general psychometric test that I recommend is the West Haven-Yale Multidimensional Pain Inventory (MPI).22 This instrument is well respected and widely used, with a focus on cognitive-behavioral aspects of chronic pain. The 52-item, 12-scale questionnaire is divided into 3 parts. Section 1 contains 5 scales: Perceived Interference of Pain in Vocational, Social/Recreational, Family, Marital/Couple Functioning; Support from Significant Others; Pain Severity; Life Control with Activities of Daily Living; and Affective Distress. Section 2 assesses patients’ perceptions of others perceptions of their pain. Further scales measure negative, solicitous, and distracting responses. Section 3 assesses patients’ participation in 4 types of daily activities: household chores, outdoor work, activities away from the home, and social activities.

Numerous studies confirm that the MPI is psychometrically sound and that it provides comprehensive information that is useful in the clinical setting.

Psychosocial Therapy

Cognitive behavior therapy (CBT), as a psychological pain treatment, has become the therapy of choice. The role of CBT evolved out of a strong history of behavior therapy that recognized that cognition or thinking was an important component of behavior change. In addition, CBT has gained further acceptance because of a growing empirical research base supporting the strength of this approach.23

An important component of the CBT approach is the assessment of the patient’s beliefs about pain. Maladaptive beliefs now are recognized as a major risk factor for poor response to treatment.24 There are a number of instruments available to assess a patient’s beliefs, but one that stands out is the Survey of Pain Attitudes (SOPA). The initial version was published in 1987.25 It has 24 items designed to assess 5 dimensions of pain beliefs: pain control, pain-related disability, medical cures for pain, solicitude from others, and medication for pain. An additional dimension, emotionality, was added in 1989. The SOPA has undergone 3 major revisions and is available in 2 short versions. Research on the SOPA has consistently demonstrated strong psychometric support.

Coping Strategies

An additional component of cognitive pain assessment is how the patient copes with pain. Coping with pain is an integral aspect in CBT. In 1984, Lazarus and Folkman defined coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.”26

This definition implies that coping is a fluid process that can change depending on demands over time. Individual differences in beliefs, personality, biology, and social roles can influence coping. It is important to recognize how the patient appraises pain, since it can greatly influence how they cope with it. Is the pain killing me or is it troublesome?

One established test to assess coping stands out— the Coping Strategies Questionnaire (CSQ).27 The CSQ was designed to assess specific coping styles. It designates 6 cognitive and 1 behavioral coping strategy. Cognitive coping strategies include: diverting attention, reinterpreting pain sensations, coping self-statements, ignoring pain sensations, praying or hoping, and catastrophizing. The behavioral subscale is: increasing activity. In addition, there are 2 self-efficacy questions assessing a patient’s perceived control over pain and ability to decrease pain. Overall, the CSQ is widely used, demonstrates research support, and is appropriate in the clinical setting.

I would like to mention one sub-construct of coping that has gained increasing attention since the CSQ was published in 1983. Catastrophizing was included in the original CSQ, which focused on a style of reacting to a stressor, including pain. From a pain perspective, catastrophizing has been defined as “an exaggerated negative orientation toward pain stimuli and pain experience.”28 From my clinical perspective, catastrophizing was a major risk factor that only recently has gained recognition. I have referred to catastrophizing as the “Chicken Little Factor.” When a patient rates their pain as a 15 on a 0-10 scale, I suspect they are catastrophizing or symptom magnifying. I also have noticed that the patient who catastrophizes usually will score high on Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI) and Group 6 on the MPQ.

As mentioned previously, this is a selection of tests available. More specifically, I have omitted many psychometric tests that rely on self-report. For those of you interested in this topic, I highly recommend Turk and Melzack’s book on pain assessment.4 

Psychophysiological Techniques

We now switch focus to psychophysiological techniques, which should not be considered in lieu of a psychosocial assessment, but rather are a complementary area of assessment. My interest in psychophysiology goes back to my undergraduate days when I studied psychology and physiology. That early interest led me to using biofeedback, which opened the door to local physicians referring headache patients to me. This was my entry point into the world of pain management, which motivated me to attend the San Francisco Biofeedback Institute and spend a summer with Johann Stoyva, a pioneer in the use of biofeedback with headache.

The role of the sympathetic nervous system (SNS) in pain experience has been well documented. In addition, there are many prominent researchers who feel pain is mediated by the SNS. If this assumption is correct, then the psychophysiological assessment of the SNS becomes an important component in the overall assessment of the pain experience. Therefore, I will focus on psychophysiological modalities that can be practically used in the clinical setting, and provide important information that complements the overall assessment of the pain patient.

Surface Electromyograph

The first modality mentioned is the surface electromyograph (EMG). It is well accepted that elevated levels of muscle tension plays a critical role in many pain syndromes including headache, temporomandibular joint (TMJ), and low back pain. Flor and Turk reviewed 60 studies using EMG on headache, TMJ, and back pain. Their analysis found inconsistent results.29 There are numerous possibilities to account for this conclusion, including equipment variability and reliability. Further, one study found lower than normal EMG resting baseline levels in fibromyalgia patients.30 What I have learned from my experience with EMG, is that the provider needs to measure resting baseline levels, then introduce a stressor, and then assess the patient’s muscle reaction and how it influenced their pain. The provider should not be surprised at the wide variability across patients with the same pain presentation.

Skin Temperature

The next modality that deserves mention is skin temperature, since it is a valid indication of sympathetic reactivity. In addition, skin temperature/vasoconstriction is associated with stress. This finding has special relevance to patients who experience circulation problems such as Reynaud’s disease. A number of studies have shown that stress causes vasoconstriction more in patients with Reynaud’s disease as compared to individuals who do not have this condition.31

On a practical clinical level, when I introduce myself to a patient, I always pay attention to the patient’s hand temperature. If it is cold, I will attach a skin thermister and monitor skin temperatures throughout the initial interview. This data then becomes part of the evaluation and subsequent treatment recommendations. The practical utility of skin temperature feedback is that the patient can leave the thermister on as they go about their day. This has 2 purposes for me in the clinical setting. The first is that it builds awareness of the mind/body connection. Second, I will use the skin temperature readings in association with the patient’s pain levels. This feedback helps determine how reactive the patient is outside the office environment. 

Electrodermal Response

The third psychophysiological modality is the electrodermal response (EDR) or, in the old parlance, galvanic skin response (GSR). Skin conductance has been shown to be a good measure of general arousal or sympathetic reactivity. In certain pain syndromes—such as complex regional pain syndrome, phantom limb pain—autonomic arousal, general arousal, or sympathetic reactivity appear to play a central role. The research on skin conductance appears to be mixed, which again reinforces the fact that each patient needs to be assessed individually. EDR is relatively easy to use in the clinical setting and does not require expensive instrumentation. Further, as compared to skin temperature feedback, EDR is faster in terms of reaction time, but in my experience with both modalities, EDR will exhibit more variability. 

Other Tests

I have left out of this section many psychophysiological modalities, such as blood flow, which is redundant to skin temperature, EEG feedback, heart rate, blood pressure, pupilometry, and respiration. These omitted modalities are considered to be more appropriate in the research setting and are not as practical in the clinical environment because of time restrictions and insurance limitations. The featured modalities of EMG, skin temperature, and EDR do not require extensive instrumentation, are relatively quick and easy to administer in the clinical setting, and, most importantly, can provide valuable information about the patient’s level of sympathetic reactivity in relation to their pain levels. 

Summary

A comprehensive psychosocial evaluation needs to include assessment of the patient’s mood, fears, expectations, coping ability, close supportive relationships, and the impact of pain on the patient’s life. All of these components complement the physical examination so that the “whole patient” can be evaluated and treated in the best fashion available. As I mentioned earlier, there is no universally accepted template for a complete evaluation, so the patient can expect to encounter a wide variety of approaches. A number of factors can contribute to this variability, including the nature of the setting, the experience level of the provider conducting the evaluation, the purpose of the evaluation, whether or not the patient is being considered for implantable pain technology, the resources available, including financial considerations, and support personnel.

I have left out other important assessments, such as assessment of chemical dependency and specialized assessments, which I will include in the next installment on the treatment of pain.

My goal was to provide creditable information for clinicians to share with their patients who experiences pain so that these patients can be more informed as consumers. In addition, I hope providers will appreciate the value of a comprehensive psychosocial, physiological, and behavioral evaluation that reinforces the view that chronic pain is a complex phenomenon.

 

Last updated on: July 10, 2015
Continue Reading:
History of Pain: The Treatment of Pain
close X
SHOW MAIN MENU
SHOW SUB MENU