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10 Articles in Volume 6, Issue #1
Bioethics
Do Topical Herbal Agents Provide Pain Relief?
Infusion Catheter Epidural
New Report of a High-Dose Morphine Metabolite
Pain Education and Pain Educators
Suspecting and Diagnosing Arachnoiditis
Tennant Blood Study — First Update
The Demise of Multidisciplinary Pain Management Clinics?
The Dimensions of Pain
The Role of Psychology in Pain Management

The Role of Psychology in Pain Management

An overview of the various roles that psychology and psychologists play in pain management.

Scene: A psychologist’s office during an initial evaluation of an individual with chronic pain; the patient shifts uncomfortably in his chair, visibly distressed, slightly confused.

Patient: “I’m in pain, I’m not crazy!” (Alternate dialogue: “If I’m seeing you, does this mean my doctor thinks my pain is all in my head?”)

Psychologist: Reassures patient that he is not crazy and that his pain experience is indeed real. Explains that psychosocial factors can contribute to the maintenance or exacerbation of the pain problem and that emotional distress can develop as a consequence of chronic pain.

This scenario repeats itself in various forms during most initial encounters between psychologists working in pain management and the patients in their care. Individuals with pain seldom spontaneously seek assistance from psychologists; the encounters nearly always involve consultation with third-party referral sources. Referring clinicians may understand that collaboration with a psychologist can be a valuable part of comprehensive pain management but may not be comfortable explaining the recommendation or psychology referral to the patient. It is evident from the concern expressed by such patients that the role of the psychologist in pain management is not always well understood. This article will attempt to familiarize the reader with the various functions a psychologist can serve in pain management within a variety of settings, and will attempt to demystify the psychological evaluation and treatment process of a patient with chronic pain.

Comprehensive Pain Models Include the Psychologist

The scope of the psychologist’s role has evolved in parallel with our expanding understanding of the pain experience. In the early days when pain was approached solely from a biomedical model, the realm of the “mind’ was considered irrelevant. The psychologist’s part in pain management was nonexistent. Although the concept of a direct correlation between specific organic pathology and pain report tended to explain acute pain fairly well, using purely physiological evidence failed to predict or adequately explain the experience of chronic pain. Clinical observations also indicated that many patients complained of persistent pain refractory to medical and surgical treatments and that functional disability often appeared in excess of what might be expected based on physical pathology alone. Specifically, the biomedical model was inadequate in situations when a patient complained of pain which was not commensurate with the degree of observable pathology. This ‘disconnect’ is common in such chronic pain conditions as back pain, headache, fibromyalgia, ‘pelvic pain,’ and temporomandibular disorders. It became obvious that other factors must contribute to the pain experience and treatment outcome. Likely contributors included psychological and social factors.

The evolution of comprehensive pain models incorporating a biopsychosocial approach has developed over decades but a thorough description of the systematic attempts to produce these models is beyond the scope of this article. It is sufficient to note that more recent pain models have been constructed to incorporate multiple dimensions of the pain experience, acknowledging that pain does not exist in a social vacuum, and that non-physiological factors such as personality, cognitions, beliefs, socio-cultural variables, learning and emotional reactivity all contribute significantly to a patient’s perception of pain. One recent model1 characterizes pain along three distinct, interrelated dimensions:

  1. sensory/discriminative, which acknowledges underlying physical pathology and incorporates nervous system pathways
  2. affective-motivational, which reflects emotional responses to pain
  3. cognitive-evaluative, which takes into account individual beliefs and ascribes meaning to the pain experience

In like fashion, Price2,3 described the experience of pain as involving:

  1. nociception
  2. primary pain affect
  3. secondary pain emotion
  4. behavioral response

Treatment based on such biopsychosocial perspectives must not only address the biological basis of symptoms, it must also incorporate the full range of social and psychological factors that are affecting the individual patient’s pain, distress, and disability. The role of the psychologist in comprehensive pain management depends, in part, on the strength of one’s acceptance of, and adherence to, a truly biopsychosocial approach to pain conceptualization and management. A therapeutic intervention that focuses predominately or solely on physiological (or social/ psychological, for that matter) factors ignores the complex and dynamic interactions among these variables at a given point in time, as well as over time, and is therefore incomplete. This approach will also likely be ineffective in the long run. Clearly, the psychologist can play an important role in working with clinicians to evaluate, identify, monitor and treat non-physiological factors contributing to a patient’s complaints.

Psychologists Fill Multiple Roles

The psychologist involvement does not have to be limited to the role of ‘last resort’ for patients with physical complaints or with disability exceeding pathophysiological explanations. Although mental health involvement can be helpful for these suspected ‘psychogenic’ or somatoform disorders, a psychologist can be involved in many other aspects of pain management of any pain condition.

Typical roles for a psychologist include:

  1. evaluator/consultant, including screener, compliance monitor, cognitive fitness judge
  2. therapist/ counselor, including pre-intervention educator, pre-intervention counselor, pain psychologist
  3. reinforcer
  4. outcomes analyst

Evaluator/Consultant

A comprehensive psychological evaluation of a patient with chronic pain can serve several functions as a complement to a medical evaluation.

The psychologist in the role of consultant or evaluator can:

  1. collect additional data regarding the patient’s pain complaints
  2. complete the ‘big picture’ psychosocial and medical history
  3. use this information to guide the establishment of individual treatment goals and algorithms
  4. suggest appropriate outcome measurement of treatment gains

Further, the psychologist in the role of evaluator or consultant can prove helpful during several critical points within a comprehensive pain management program. The following sections elaborate on various roles in this category.

Screener

Patients can be evaluated pre-treatment, including prior to surgery; before an implant trial; pre-implantation of spinal cord stimulator or drug administration system; before beginning pharmacological treatment (especially chronic opioid therapy); or prior to participation in a multidisciplinary pain management program.4

The initial patient evaluation can:

  1. create a picture of the “person behind the pain”
  2. flag warning signs for potential patient noncompliance
  3. provide an estimated prognosis based on psychosocial barriers or boons to recovery
  4. establish whether psychological counseling for emotional distress might improve chances of treatment success
  5. guide the health care team in creating appropriate and realistic treatment goals and algorithms
  6. indicate whether pre-treatment education (e.g., about surgical risks/possible benefits, about rules of clinic’s opioid agreement) addiction recovery, behavior change (e.g., smoking cessation, weight management) or counseling is warranted

In fact, many companies that produce and advocate interventions such as spinal cord stimulators (SCS) or drug administration systems (DAS) recommend pre-trial psychological screening of all patients.

In addition, a pre-treatment psychological evaluation can suggest appropriate outcome measures to determine the success of the prescribed intervention. For example, for a patient that continues to work full time despite pain, but who exhibits significant anxiety and withdrawal from recreational and social activities, return-to-work or physical therapy quotas may not be the ideal post-intervention outcome measurements. Instead, one might consider administering measures of anxiety, quality of life, social support, or pain beliefs at various points during treatment to assess change in these domains important for this particular individual.

Compliance Monitor

If a patient violates the terms of a clinic’s opioid agreement by having an abnormal urine drug screen, missing several appointments, seeking prescriptions or medications from other providers without alerting the clinic, or otherwise exhibiting behaviors prohibited by the agreement, a psychologist can be instrumental in patient management.

The psychologist’s participation in compliance monitoring serves as a safeguard for the prescribing physician. If the patient presents with a positive urine drug screen, for instance, the psychologist can help assess why the unexpected or unauthorized substance was present. Careful questioning and assessment may shed light on whether the patient is struggling with new addiction issues, is experiencing a relapse of substance abuse, was engaged in one-time recreational use of an illicit substance, or is engaging in chemical coping instead of appropriate coping skills. The psychologist can assist the physician in making a judgment whether to discharge the patient from treatment for violating the opioid agreement, to educate the patient after a “first strike” violation, or to help the patient get appropriate counseling. In some cases, patients committing a ‘minor,’ or one time, violation may become very compliant and successful patients with the help of the psychologist. Merely discharging each of the patients ‘to the street’ rarely helps the problem. The psychologist can assess whether there are personality characteristics that are involved in chronic violations, excessive health care utilization, or ‘doctor shopping,’ and can also educate patients on appropriate ways to safely store and safeguard medications.

Cognitive Fitness Judge

Many patients involved in pharmacological management wish to, or are expected to maintain, ‘normal’ daily activities including work, operating machinery/automobiles, maintaining a household, etc. These activities require adequate attention, memory, concentration, and prompt reactions which may be affected by various pharmacological agents, including opioids. In such situations, questions of ‘fitness for duty’ may arise.

Neurocognitive testing can be very useful in assessing cognitive impairment that may impose restrictions on certain functions. Objective test data can be very helpful to the prescribing physician and provide some ‘protection’ in medical-legal situations. A neurocognitive testing battery can also screen patients with dementia, traumatic brain injury or attentional difficulties associated with post-traumatic stress or other disorders which may affect their compliance and response to pharmacological therapy. While no single test or battery of tests has been found to correlate in a one-to-one fashion with certain tasks such as driving, neurocognitive testing can provide a fairly accurate assessment of memory, attention, reaction time, general processing accuracy, and efficiency. Patients can be ‘released’ to function and work within the confines of the test parameters. In addition, the results of testing can also guide the development of cognitive rehabilitation therapies for cognitively impaired patients.

In summary, there are several advantages to having a psychologist conduct these comprehensive evaluations as part of one’s pain management team:

  1. Medical-legal safeguard
  2. Implementing the biopsychosocial model
  3. Increased knowledge of patient
  4. Help establishing appropriate treatment goals (improve chance of success)
  5. Identification of "red flags"
  6. Identification of psychosocial factors which can affect treatment outcome
  7. Individualized treatments for specific behavioral problems

Therapist/Counselor

A quick survey of laypersons would likely reveal perceptions of psychological treatment similar to versions of therapy sessions portrayed in the media. These dramatized sessions often include a patient reclining on a couch, discussing vivid dreams or complaining about their mother, the therapist nodding slightly and offering the occasional, “So, how does that make you feel?” Certainly, individual therapy is one component of a psychologist’s training and expertise, but it does not usually take the form described above, especially when the patient is experiencing chronic pain.

Setting the Scene for Psychological Treatment

Psychologists may be called upon to provide treatment at various stages of pain management, filling different roles at different times.

Pre-Intervention Educator. Patient education can be helpful any time during the treatment process. However, education can be especially critical before certain pain management interventions.

Informational sessions can involve both the patient and family in order to:

  1. prepare and educate about a specific procedure (e.g., surgical implantation of a SCS; definitions of addiction vs. tolerance vs. dependence)
  2. clarify and reorient the patient to appropriate outcome expectations
  3. set appropriate and manageable goals
  4. increase motivation. Education itself can serve to reduce fear and anxiety about actual surgical/medical procedures, the recovery process, risks, and alternatives

Educational sessions might typically involve distribution of written material about a particular procedure, presentation of videos depicting surgical methods (e.g., of SCS or DAS implantation), and discussion about the patient’s particular concerns.

Pre-Intervention Counselor. If patient’s concerns about a particular recommended intervention persist even after they are well-informed of the process, pre-intervention counseling can then be beneficial.

This targeted counseling can help the patient alter negative perceptions about the intervention. If a psychological assessment was conducted prior to trial or implantation of an intrathecal infusion pump, spinal cord stimulator, or surgery (e.g., fusion, laminectomy), the psychologist can use that information to determine and treat specific psychological risk factors for chronic pain/disability that may present barriers to recovery following surgery or implantation.

Consider the patient who fears the stigma or addiction potential of a regimen of oral opioids. This patient can benefit from discussions designed to help them identify their beliefs about pain and pain treatment and generate alternative beliefs that are more adaptive and productive. Role-playing can help the patient become an assertive health care consumer and learn how to appropriately ask questions and effectively interact with their physicians and whole treatment team. Cognitive-behavioral therapy to reduce significant emotional distress prior to intervention can increase the likelihood of the best possible post-intervention outcome.

Therapies for behavior change, such as smoking cessation or weight management, are also helpful at this pre-intervention stage so that surgical recovery is enhanced. Beginning counseling at this stage can also establish a support system that can last throughout the duration of the intervention and be in place well ahead of crisis moments.

Pain Psychologist. Psychological/behavioral therapy can be effective and helpful prior to, during, and after ‘medical’ therapies, in conjunction with these therapies and, in some instances, as an alternative to medical therapies.

Such therapy is useful to:

  1. help the patient understand the dynamic interaction between pain and mood
  2. help reduce emotional distress associated with the chronic pain experience
  3. address long-standing psychopathology
  4. help the patient develop adaptive strategies and skills to cope with stress and pain

Psychological treatment for an individual with chronic pain can be provided in a variety of formats: individual therapy, group therapy, family counseling, or group psychoeducational sessions. Approaches vary, but typically fall under the umbrella terms of behavioral or cognitive-behavioral therapy (CBT). CBT for chronic pain is a term that covers a wide array of interventions that share a set of theoretical assumptions about interactions between thoughts/cognitions, mood, behaviors, and environmental events that combine to determine patients’ subjective pain perceptions. CBT interventions involve education and skills acquisition. CBT is often used in conjunction with other behavioral therapies and may include:

  1. Biofeedback and relaxation training (e.g., diaphragmatic breathing, progressive muscle relaxation, autogenic training, self-hypnosis, guided visual imagery) to reduce muscle tension and promote the body’s calming response
  2. General stress management techniques (e.g., time management, problem-solving skills, assertive communication)
  3. Health promotion (e.g., nutrition and exercise, sleep hygiene)
  4. Anger management skills training
  5. Increasing understanding of personality style and its contribution to the pain experience
  6. Activity pacing and reducing fear of pain and/or activity avoidance
  7. Increasing acceptance of the chronic nature of pain condition
  8. Reinforcement (i.e., “operant”) techniques to increase adaptive behaviors and decrease maladaptive pain behaviors
  9. Cognitive approaches to manage clinical depression and anxiety disorders
  10. Cognitive approaches to foster thoughts, emotions and actions that are adaptive for managing a life with pain

Cognitive approaches involve an examination of appraisals, beliefs, attributions and expectations regarding the causes, effects, alteration and acceptance of pain and associated dysfunction. Once any negative or counterproductive thoughts are clarified, patients are taught to construct alternative thoughts that are more realistic and adaptive. For patients with pain, this may involve helping them rid themselves of their identity as a “pain patient” and working toward an acceptance that, although their pain may not be cured, they can live a satisfying life despite the pain.

Cognitive-behavioral therapy can be an effective pain management technique. Researchers have reported CBT’s benefit in patients with pain from rheumatoid arthritis or osteoarthritis,5 fibromyalgia,6 and low back pain,7 among other pain syndromes. Psychological therapies, including cognitive-behavioral, have often been dismissed as dealing with the ever illusive vagaries of the mind, or ‘black box.’ The results are thought to be less profound, ‘scientific,’ or enduring compared to more medical interventions. This position, however, is a result of a lack of awareness and understanding of the mechanisms of change involved in psychological, and in particular, behavioral therapies. The most obvious mechanism is via a change in overt (i.e., observable) behavior including the way one acts and talks. Somewhat less obvious are the ‘cognitive’ changes such as one’s covert self-talk, thoughts and beliefs. Physiological changes, including musculoskeletal activity, heart rate, blood pressure, EEG patterns, and general sympathetic arousal, can also be altered. In addition to these mechanisms, changes have also been noted in the production of endogenous opioids, neurotransmitters (e.g., 5-HT, NE, CCK), neurohormonal activity, and cortical functioning (e.g., blood flow to frontal cortex and anterior cingulate gyrus in the limbic system). Birbaumer and Flor8 have indicated changes in synaptic connections as a result of the application of conditioning/learning principles, i.e., behavioral therapies. Indeed, Eric Kandel, Nobel Laureate Physiology/ Medicine, 2000, stated that “Insofar as psychotherapy…produces long-term changes in behavior, it presumably does so through learning, by producing changes in gene expression…that alter the anatomical pattern of interconnections between nerve cells of the brain…the regulation of gene expression by social factors makes all bodily functions, including all functions of the brain, susceptible to social influences.”9

“Cognitive-behavioral therapy can be an effective pain management technique. Researchers have reported CBT’s benefit in patients with pain from rheumatoid arthritis or osteoarthritis,5 fibromyalgia,6 and low back pain,7 among other pain syndromes.”

Reinforcer. An important concern for pain management clinicians is the extent to which patients maintain their therapeutic improvements. This is a critical issue given the increased emphasis on outcomes and the demand for health care providers to justify the costs of their services. Similar to the relapse prevention models within the addiction literature, Keefe and Van Horn10 have suggested that ‘relapse’ of pain complaints/behavior tends to occur when patients’ symptoms increase in intensity, their perceived abilities of control are compromised, and their psychological distress is magnified. ‘Relapse prevention’ interventions may produce improved outcomes by helping patients to recognize and cope with these situations. This includes post-surgical outcomes where the continuation of exercise and proper ‘spine care’ can be the difference between a long term success or failure. Psychologists can help patients practice newly honed coping skills and pain management strategies in high-risk situations, and provide continued services during follow-up.

Outcomes Analyst. In an era of increased emphasis on ‘evidenced based medicine’, documenting outcomes has taken on renewed importance. Most doctoral level psychologists have training in research methodology and analysis. This training places them in a unique position of being able to develop protocols for applied research and outcome studies. Outcomes analysis is important at all levels. Indeed, the Federation of State Medical Boards and most individual state medical boards emphasize the importance of documenting outcomes in the use of opioids for treating chronic pain. Determining the most meaningful of the many measures available and what constitutes a positive outcome remains an issue.11 The time honored disease-specific measures—such as numerical rating scales and visual analogue scales—appear inadequate, especially in a clinical setting. These measures need to be supplemented by the more ‘generic’ outcomes, including quality of life, patient satisfaction, and overall health assessments.12 The lack of clarity as to which, and how many, of these measures should be used, however, does not exonerate the clinician from evaluating their treatments. Accurate and meaningful data can provide a basis for proper patient and clinician expectations as well as the development of therapeutic algorithms or alteration of an existing treatment. This often forms the basis for evidence-based medicine. In the absence of a meaningful and critical analysis of pain therapies, one is destined to perpetuate past inadequacies in exposing patients to ineffective, if not needless, therapies. It has been said that “insanity” equates to doing the same thing over-and-over, expecting a different result. Unfortunately, there are clinicians for whom ‘blatant assertion’ still constitutes an acceptable statement of their outcomes.

Setting the Scene for Psychological Evaluation

So, what can you expect if you request a consultation or refer a patient for a psychological evaluation? Evaluations can be conducted in office or at bedside during a hospital inpatient consultation. In either case, the psychologist uses several tools in tandem to help them conceptualize the patient’s situation and derive suggestions for treatment, including an interview, careful behavioral observation, and psychometric testing.

Interview. The usual first step—and main event in any psychological evaluation—is the interview. This may be conducted in a structured or unstructured format. Interviews will routinely involve caretakers, spouses, significant others, and/or relevant family members to gather information about possible secondary gain/reinforcement issues, communication patterns, and to secure the most accurate and complete historical information.

A thorough interviewer will gather information from the patient spanning several domains, including:

  1. pain description and history
  2. coping strategies
  3. ‘stage of readiness’ for treatment and change
  4. contributing psychosocial factors

In addition, the psychologist can gather critical information about the patient’s substance use history, current medication adherence, and cognitive or behavioral barriers to appropriate medication use. Finally, the psychologist is trained to make specific behavioral observations throughout the interview about the patient’s obvious or subtle pain behaviors, affect, cognitive limitations, mental status, communication style, and pathological personality indicators. The specific information collected during the interview is flexible and may vary depending on the patient, the psychologist, and the needs of the referring physician. Typical interview topics are summarized in Table 1.

Assessments relying solely on interview data are often considered incomplete, if not inadequate. Paper-and-pencil tests are recommended to examine consistency of patient self-report and to provide quantitative data for repeat comparison. Such tests can measure mood symptom severity, perceived disability, personality factors, and can expand patient qualification and quantification of their pain.

Measurement and Testing Tools

Common questionnaires include the McGill Pain Questionnaire (MPQ), a valid and reliable measure that presents several groups of verbal pain descriptors to the patient in four major groups: Sensory; Affective, Evaluative and Miscellaneous.13 The MPQ can either be filled out by the patient as a paper-and-pencil test, or administered by an evaluator reading each subclass of words as a concise way of measuring subjective pain experience. Studies have shown that the MPQ is able to discriminate among discrete pain conditions14 and that it is sensitive to interventions designed to reduce pain.15 A psychologist can use the information from the MPQ to guide interventions. For example, if a patient endorses several affective pain descriptors of high intensity (i.e., the patient chooses words such as “terrifying,” “unbearable,” “vicious”), the psychologist may design an intervention that targets pain anxiety, maladaptive pain beliefs, unrealistic expectations, or coping mechanisms. This plan may differ from a psychological treatment program designed for a patient that primarily endorses sensory descriptors such as “aching,” “tender,” and “cramping,” in which techniques such as muscle relaxation may be better suited.

One of the most commonly used self-report instruments in clinical settings for evaluating the psychological status of patients with chronic pain is the Minnesota Multiphasic Personality Inventory–II.16,17 The MMPI-II is a 567-item true-false personality measure. The patient’s score profile on its three validity scales and ten clinical scales can provide a clinician with a sense of the patient’s reporting style (e.g., openness, defensiveness, “faking good” or “faking bad”), as well as clinical levels of somatic focus, emotional reactivity, depression, anxiety, anger or hostility, defensiveness, suspicion, and confusion. Certain MMPI-II profile patterns and behavioral correlates have been identified among independent samples of patients with back pain18 and other diverse chronic pain syndromes.19,20 Again, psychologists can use information from this measure to guide treatment plans and to suggest “red flag” personality characteristics to referring physicians. For example, a patient with an MMPI profile suggesting high levels of hostility, resistance to authority, and an elevated energy level may tend to test limits and may exhibit medication compliance issues down the line.

Depression is one of the more common psychological comorbidities in patients with chronic pain.21 Two brief measures are often used to assess depression. The Beck Depression Inventory (BDI)22 has 21 items that measure somatic and affective symptoms of depression experienced by the patient over the past week. Another tool for measurement of depression is the Center for Epidemiological Studies – Depression Scale (CES-D),23 which contains fewer items with somatic content and may be less prone to artificial score inflation in patients with somatic complaints related to chronic pain itself. Geisser and colleagues24 found that both the BDI and CES-D significantly discriminated between patients with chronic pain who did, or did not, have major depression.

Of course, several other domains of psychological functioning can be measured to provide a comprehensive picture of the patient’s emotional distress and available coping resources. Valid and reliable self-report measures of anger, general anxiety, coping style, level of ‘acceptance,’ pain anxiety and avoidance, readiness for change, pain beliefs, family environmental contributions, and other psychosocial constructs are available and can provide useful information to guide the psychologist in matching the psychological treatment to the individual patient’s needs.

In addition to measures of the pain experience, personality and emotional distress, a testing battery often includes a measure of functional disability. Several measures are available; some measure disability from general pain (e.g., the Sickness Impact Profile, the West Haven-Yale Multidimensional Pain Inventory), and others measure pain interference from specific conditions or body areas. The Oswestry Low-Back Pain Disability Questionnaire,25 for example, is a measure of perceived disability and activity interference due specifically to back pain. The psychologist can use this information to examine the patient’s overall perception of pain interference, the domains of functioning (e.g., sitting, socializing, lifting) most affected by the patient’s pain, as well as activities the patient can still adequately perform. The physician can then use this information to guide appropriate medical intervention, to improve functional ability, and assess the outcome of treatment.

Pain-Related Information Psychosocial Information Medication/Adherence Issues Behavioral Observations
Pain location, ratings, description Brief social history Medication management (e.g., list of medications, doses, prescribing physician, side effects, etc.) Good/poor historian
Pain and treatment history Family reactions to pain Substance use/abuse history Mental status (brief assessment)
Exacerbating factors Current mood status (e.g., depression, anxiety, anger, frustration, presence of affective disorders) Adherence to medications (e.g., dose timing, missed doses, running out ahead of time) Interaction with family members
Helpful interventions Psychological history Side effects Personality indicators
Impact of pain on activity Suicidal ideation and intent for self-harm Signs of tolerance Pain behaviors
Activity pacing efficacy Legal or social reinforcements /secondary gain Irrational fears of addiction Barriers to medication compliance (e.g., poor judgment, impulsivity, poor memory)

Understanding of diagnosis and prognosis

Current coping resources    

Expectations for treatment gains

Social support    

 

 

Readiness for change/Acceptance    
Table 2. Possible psychological interview topics.

The actual battery of questionnaires used by the psychologist in their evaluation will vary based on the needs of the clinician, personal preference or clinic setting. It is considered ‘best practice’ to use information from personality profiles and other questionnaire measures only in conjunction with clinical observations and historical data collected during the interview. To minimize biases inherent in single self-report measures, psychologists often avoid relying on a single measure to assess a content domain. However, they also try to balance their need for information with protection of the patient from an overwhelmingly thick packet of questionnaires.

Finally, testing can also include structured measures designed to examine neurocognitive functioning. Cognitive and neurological processes such as attention, concentration, planning, reaction time, and memory may be impaired in patients with pain.26 In younger patients, cognitive deficits may result from head injuries or other organic processes, interference from pain itself, or medication effects. In elderly patients, cognitive impairment may also occur as a result of dementia or increased susceptibility to side effects of pain medications. Brief screening tools such as the MicroCog are computerized, easy to administer, can be sensitive to cognitive changes over time, and give some basic information about the cognitive processes listed above.27 Psychologists trained to administer and interpret neuropsychological tests can also conduct formal neuropsychological batteries to examine suspected cognitive deficits in a more comprehensive and thorough manner.

Conclusion

Do you really want to implant a spinal cord stimulator or drug administration system in a patient with borderline personality disorder? Do you really want to perform that second or third spine surgery for complaints of pain on a patient striving for disability? Do you really want to give opioids to a person with undiagnosed drug abuse problems? Do you really want Medicare to review your charts for proper documentation of treatment outcome data? If not, consider the involvement of a pain psychologist.

The question often arises as to how to find a pain psychologist. There are at least three avenues. First, obtain the membership rosters from the American Pain Society and the International Association for the Study of Pain. Members are listed by location and specialty. Second, contact the nearest institution hat grants a doctoral degree in psychology. The department of psychology often is aware of graduates in the area and their special interests. Third, contact the local state board of examiners in psychology. They also have information on local psychologists. Of course, advertising via any of the above organizations or in the many psychological/pain publications/journals can be fruitful. If there are psychologists in your area, arranging a meeting and discussing your needs and the opportunities to expand their practice could pay dividends. Once a person is identified, there may be some practical and financial advantages to having them as an employee of the practice vs. using them as an outside consultant. For those psychologists interested, but requiring some additional training, there are many such opportunities through assorted workshops offered by the various local, regional, and national pain societies. In some instances, such as in the authors’ clinic, brief proctorships can be arranged.

The role of the psychologist can vary widely in the same way that ‘clinics’ can range from ‘one-man’ injection clinics to ‘full service’ interdisciplinary clinics. Psychologists may function as a consultant to the practitioner, member of a multidisciplinary team, or head of a division/program. It is well established that comprehensive treatment settings are successful in treating all aspects of a pain patient’s condition. This type of setting seems to convey an interest in the person as a whole rather then a mere receptacle of treatment. The presence of a pain psychologist all but guarantees that the all-important affective or ‘suffering’ component of pain, especially chronic pain, is successfully attended to.

Last updated on: May 8, 2017
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