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Topics in Assessment of Chronic Pain



1: Pain Physician. 2002 Jan;5(1):57-82.Read full text article.

Understanding psychological aspects of chronic pain in interventional pain management.

Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, USA.

There is no doubt that chronic pain is recognized as a biopsychosocial phenomenon in which biological, psychological, and social factors dynamically interact with each other. Thus, the role of psychological factors and understanding chronic, persistent disabling pain has been well recognized, but poorly understood. Approximately 1/2 to 2/3 of all patients diagnosed with chronic pain manifest to various levels of psychological distress. Chronic pain and psychological disorders are the two most common elements in the United States. Statistics show that, approximately 22% of Americans suffer from a diagnosable mental disorder in a given year. In addition, 28% of the American population suffers with chronic pain. Depression in chronic pain is the most common condition, followed by generalized anxiety disorder, somatization disorder, and drug dependence. However, psychogenic pain appears to be the least prevalent of all psychopathological issues. Chronic pain disability is a complex psychosocial economic phenomenon. There is no data in the literature with regards to treatment of personality disorders, anxiety disorders, and somatization disorders in managing chronic pain. In contrast, treatment of depression and the influence of treatment on outcomes have been studied to some extent. In conclusion, patients with chronic pain frequently have psychopathology - most often common depressive disorders, anxiety disorders, somatization disorders, drug dependence and occasionally personality disorders. This review discusses various issues involved with psychopathology in chronic pain including epidemiology; relationship of psychopathology to pain; influence of depression, generalized anxiety disorder, somatization, and personality disorders on chronic pain, along with diagnosis and management in interventional pain management.

PMID: 16896359 [PubMed]


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1: Pain Physician. 2005 Oct;8(4):375-83.Read full text article.

Reliability of psychological evaluation in chronic pain in an interventional pain management setting.

Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, USA.

BACKGROUND: Psychological disorders may be associated with poor pain related treatment outcomes. However, there may be limitations with studies evaluating the relationship between pain and psychopathology. OBJECTIVE: To assess the reliability of psychological evaluations in interventional pain management by MCMI-III(R) and P-3(R). STUDY DESIGN: Prospective evaluation of consecutive patients in an interventional pain management center. METHODS: Patients were evaluated using a DSM-IV-TR(R) questionnaire with a physician interview as an integral part of their comprehensive evaluation. In addition, all the patients participating in this study also underwent psychological evaluation with MCMI-III and P-3. A positive diagnosis of major depression or generalized anxiety disorder based on DSM-IV-TR criteria was considered as the criterion standard. All of the patients presented for treatment of chronic pain. The data based on the criterion standard were compared with results of the diagnostic impression from the MCMI-III and the P-3 evaluation utilizing criteria for average, and above average, patient pain scores. RESULTS: Major depression was diagnosed in a total of 59 of 100 patients using DSM-IV-TR criteria, in 32 patients based on MCMI-III criteria, and in 55 patients based on P-3 evaluations utilizing average pain patient criteria. Generalized anxiety disorder was diagnosed in 55 patients by means of DSM-IV-TR, 45 patients by MCMI-III, and 55 patients by P-3 Profile utilizing average pain patient scores. The specificity of MCMI-III was 100% with a sensitivity of 54% for diagnosis of depression; whereas it was 78% specificity and sensitivity for P-3, with average pain patient scores. For generalized anxiety disorder, specificity of MCMI-III was 89% with a sensitivity of 73% compared to specificity of 80% and sensitivity of 84% for average pain patient scores for P-3. CONCLUSION: MCMI-III and P-3 are highly specific in diagnosing depression and generalized anxiety disorder, with variable sensitivity. A DSM-IV-TR questionnaire evaluation incorporated into the pain management questionnaire, along with a short clinical interview, is a reliable means of assessing depression and anxiety in patients suffering with chronic pain.

PMID: 16850061 [PubMed]


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1: Pain Physician. 2002 Apr;5(2):149-55.Read full text article.
Comment in:
Pain Physician. 2002 Oct;5(4):440-1; author reply 441-4.

Evaluation of psychological status in chronic low back pain: comparison with general population.

Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, USA.

Multiple studies have documented a strong association between chronic low back pain and psychopathology including personality disorders, depressive disorders, anxiety, and somatoform disorders along with non-specific issues such as emotion, anger and drug dependency. However, depression, anxiety and somatization appear to be crucial. There are no controlled trials in interventional pain management settings. This study was designed to evaluate 40 individuals without pain or psychotherapeutic drug therapy, Group I, control group; and Group II, chronic low back pain group with 40 chronic low back pain patients. All the participants were tested utilizing Pain Patient Profile (P3). Significant differences were found among various clinical syndromes with generalized anxiety disorder, somatoform disorder, and depression, with 0% vs 20%, 0% vs 20%, and 5% vs 30% in Group I and Group II consecutively. This evaluation showed that clinical syndromes were seen in a greater proportion of patients with chronic low back pain emphasizing the importance of evaluation of the patients for generalized anxiety disorder, somatoform disorder, and for depression.

PMID: 16902665 [PubMed]


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1: Pain Physician. 2002 Jan;5(1):40-8.Read full text article.

Comparison of psychological status of chronic pain patients and the general population.

Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, USA.

This study was designed to evaluate the psychological status of 50 individuals without chronic pain and without psychotherapeutic drug therapy, Group I, the control group; and Group II, a chronic pain group with 100 chronic pain patients. All the participants were tested utilizing Millon Clinical Multiaxial Inventory III (MCMI-III). Results were analyzed and compared for various clinical personality patterns, including personality traits and personality disorders; severe personality pathology for schizotypal, borderline and paranoid personality pathology; and multiple clinical syndromes, including generalized anxiety disorder, somatization disorder, major depression, bipolar manic disorder and dysthymic disorder, etc. There were no significant differences noted in clinical personality patterns or severe personality pathology. In the analysis of clinical syndromes, generalized anxiety disorder (40% vs 14%), somatization disorder (26% vs 0%), and major depression (22% vs 4%) were seen in a greater proportion of patients in the chronic pain group. The prevalence of psychological disorders in the control group was 24%, compared to 55% in chronic pain group. In conclusion, this evaluation showed that clinical personality patterns are present in both groups of patients. Psychological abnormalities such as generalized anxiety disorder, somatization disorder, and major depression are commonly seen in chronic pain patients.

PMID: 16896357 [PubMed]


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1: South Med J. 2005 Nov;98(11):1099-110; quiz 1111-2, 1138.Read full text article.
Comment in:
South Med J. 2005 Nov;98(11):1063.

Psychosomatic pain: new insights and management strategies.

Neurological Associates, 2685 SW 32nd Place, Suite 100, Ocala, Florida 34474, USA.

At least 40 to 60 percent of women and at least 20 percent of men with chronic pain disorders report a history of being abused during childhood and/or adulthood. This incidence of abuse is two to four times higher than in the general population. Patients with more severe or frequent abuse, usually during childhood and worse if sexual in nature. often develop specific syndromes or combinations of syndromes. These syndromes include posttraumatic stress disorder, fibromyalgia, and other conditions characterized by repression, somatization, and increased utilization of medical care. Psychosomatic symptoms and dysfunctional behaviors may emerge as these patients seek attention and validation of their suffering, while paradoxically repressing painful memories of trauma. Behavioral observations and key features of the physical examination may greatly help the clinician identify both the presence and severity of psychosomatic disease. In addition, it is very interesting that various studies document physiologic changes in the brains of patients with a history of abuse and in patients with a diagnosis of fibromyalgia. These studies suggest that abuse may physiologically and developmentally increase a person's susceptibility to pain and that some organic changes may be associated with psychogenic disease. Diagnosis and treatment of even the most challenging patients with chronic pain is much more effective if it includes (a) careful inquiry about any history of past or present abuse or other severe trauma, (b) empathy and constructive validation of disease and suffering, (c) recognition of dysfunctional pain behaviors and personality traits, (d) documentation of nonanatomic as well as anatomic features on examination, (e) multidisciplinary treatments including psychotherapy whenever indicated, and (f) noninvasive procedures and alternatives to potentially habit-forming medications whenever possible and appropriate. Furthermore, it has been shown that helping patients gain insight about the relationship between abuse and their current symptoms leads to decreased health care utilization. Practical guidelines are provided for identifying psychopathology, communicating effectively, and achieving better treatment outcomes for these unfortunate patients.

PMID: 16351031 [PubMed - indexed for MEDLINE]


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1: Spine. 2004 Oct 15;29(20):2290-302; discussion 2303.Read full text article.

The pain disability questionnaire: a new psychometrically sound measure for chronic musculoskeletal disorders.

PRIDE Research Foundation, Dallas, TX 75235, USA.

STUDY DESIGN: The Pain Disability Questionnaire (PDQ) is a psychometric evaluation study of a new measure of functional status. OBJECTIVE: To evaluate the psychometric properties of the PDQ and compare its validity and responsiveness to traditional measures of functional status, such as the Oswestry, Million (MVAS), and SF-36 instruments. SUMMARY OF BACKGROUND DATA: Measuring clinical outcomes is an essential element of any musculoskeletal treatment. The PDQ was developed for this purpose. It yields a total functional disability score ranging from 0 to 150. The focus, much like other health inventories, is primarily on disability and function. However, unlike most other measures, this instrument is designed for the full array of chronic disabling musculoskeletal disorders (CDMDs), rather than low back pain alone. Further, psychosocial variables, which recent studies have shown to play an integral role in the development and maintenance of chronic pain disability, formed an important core of the PDQ. METHODS: Four groups were used in this psychometric evaluation: an asymptomatic normative population (NP; n = 50), an acute musculoskeletal disorder population (AMD; n = 52), a chronic disabled musculoskeletal disorder population (CDMD; n = 230), and a heterogeneous pain population (HP; n = 114). The NP and AMD groups served as comparison samples for the CDMD and HP groups. Analyses of PDQ reliability, validity, and responsiveness were conducted. RESULTS: Test-retest reliability coefficients (ranging from 0.94 to 0.98) and a Cronbach's alpha coefficient of 0.96 for the PDQ were found to be of excellent quality. The responsiveness of the PDQ, as measured by Cohen's effect size statistic, ranged from 0.85 to 1.07, better than the Oswestry, MVAS, and SF-36. A high level of face validity was observed for the PDQ, as the CDMD population exhibited significantly higher pretreatment PDQ scores than a group of patients suffering from acute injuries. The construct-related validity of the PDQ was also found to be of excellent quality, as it correlated well to both the MVAS (0.65-0.81) and Oswestry (0.55-0.80). The PDQ consistently demonstrated stronger correlation coefficients to a wide variety of physical and psychosocial measures of human function, such as the SF-36, Beck Depression Inventory, Hamilton-D, State-Trait Anxiety Scale, and Pain Intensity VAS, than either the Oswestry or MVAS. A factor analysis of the PDQ revealed two factors: a Functional Status Component (FSC) and a Psychosocial Component (PC). Analyses proved each of these two components to be valid in assessing their theorized constructs. CONCLUSIONS: The present study represents a comprehensive psychometric evaluation of a new functional status measure for musculoskeletal conditions in general, and a CDMD population in particular. The psychometric properties of the PDQ are excellent, demonstrating strong reliability, responsiveness, and validity, relative to many other existing measures of functional status. The many weaknesses cited for some of the existing measures were taken into account in designing this instrument. Consequently, the characteristics commonly noted as weaknesses for these other measures (such as a restriction to only the low back pain population, and inconsistent responsiveness) can be cited as strengths of the PDQ. Its generalizability and utility for assessing orthopedic treatment progress and functional outcomes must now be evaluated in broader settings.

PMID: 15480144 [PubMed - indexed for MEDLINE]


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1: Pain Med. 2007 Oct-Nov;8(7):601-10.Read full text article.

Pain assessment in younger and older pain patients: psychometric properties and patient preference of five commonly used measures of pain intensity.

Department of Clinical Psychological Science, University Maastricht, Maastricht, The Netherlands.

OBJECTIVE: To study the psychometric properties and preference for five different pain intensity scales (horizontal visual analog scale [VAS], vertical VAS, Box-11, Box-21, and verbal descriptor scale) across different age groups. DESIGN: Chronic pain patients rated their present, average, weakest, and strongest pain on five different scales, and indicated scale preference. SETTING: Outpatient pain facility. RESULTS: The number of mistakes on all scales increased with increasing age, and the VAS appeared to be most prone to making mistakes. All scales appeared to be sufficiently valid, but the verbal descriptor scale was less related to the common underlying pain factor than the other scales. The Box-21 was the most preferred scale overall, although patients aged >75 years especially preferred the verbal descriptor scale. CONCLUSION: The numerical Box-21 scale is an excellent choice for pain intensity assessment in heterogeneous patient groups. The verbal descriptor scales may be considered when the study population consists of a majority of older persons.

PMID: 17883744 [PubMed - in process]


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1: Am Fam Physician. 2007 Jul 15;76(2):247-54. Links
Comment in:
Am Fam Physician. 2007 Jul 15;76(2):195-6, 202.


Department of Family and Community Medicine, Meharry Medical College, Nashville, TN 37208, USA.

Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid conditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective.

PMID: 17695569 [PubMed - indexed for MEDLINE]

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1: Health Psychol. 1995 Sep;14(5):415-20.Read full text article.

Predicting outcome of chronic back pain using clinical predictors of psychopathology: a prospective analysis.

Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas 75235-9044, USA.

This study evaluated whether a comprehensive assessment of psychosocial measures is useful in characterizing those acute low back pain patients who subsequently develop chronic pain disability problems. A cohort of 324 patients was evaluated, with all patients being administered a standard battery psychological assessment tests. A structured telephone interview was conducted 6 months after the psychological assessment to evaluate return-to-work status. Analyses, conducted to differentiate between those patients who were back at work at 6 months versus those who were not because of the original back injury, revealed the importance of 3 measures: self-reported pain and disability, the presence of a personality disorder, and scores on Scale 3 of the Minnesota Multiphasic Personality Inventory. These results demonstrate the presence of a psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems.

PMID: 7498112 [PubMed - indexed for MEDLINE]



1: Curr Opin Anaesthesiol. 2007 Oct;20(5):485-9.Read full text article.

Current psychological approaches to the management of chronic pain.

Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA.

PURPOSE OF REVIEW: To provide a review of the rationale and evidence supporting three frequently used psychosocial interventions for chronic pain: cognitive-behavioral therapy, operant behavioral therapy and self-hypnosis training. We also review recent work in these areas, with an emphasis on the 2006 publishing year. RECENT FINDINGS: Recent clinical trials and laboratory work continue to support the use of cognitive-behavioral therapy and operant behavioral therapy as adjunctive treatments for chronic pain. Notable areas of new research include a novel program of systematic exposure to pain-related fear (such as fear of reinjury) and the adaptation of cognitive-behavioral therapy for special pain groups (e.g. juveniles and those with pain secondary to physical disability). Regarding self-hypnosis training, recent work suggests that hypnosis can provide temporary pain relief to the majority of individuals with chronic pain and that a substantial minority of these patients experience a clinically significant reduction in baseline pain over time. SUMMARY: Cognitive-behavioral therapy and operant behavioral therapy treatments focus on factors that exacerbate or maintain suffering in chronic pain, and should be considered as part of a multidisciplinary treatment paradigm. Self-hypnosis training may also be of benefit, although it appears to be no more (or less) effective than other relaxation strategies that include hypnotic elements.

PMID: 17873602 [PubMed - in process]


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