psychological evaluation of the patient in pain

1. Psychological Evaluation of the Patient in Pain Alfredo Romero, MD

3. Indication for Psychological Evaluation Affected patient�s ability to engage in normal activities Affected interpersonal relationships Patient shows signs of significant psychological distress (e.g depression, anxiety) Patient repeatedly and excessively uses the health care system Patient persists in seeking invasive investigations or treatments after being informed these are not appropriated Inappropriate use of opioid, sedative-hypnotic medications or alcohol

4. Purposes of a Psychological Evaluation The primary goal is to identify emotional and behavioral factors that may be complicating or perpetuating the clinical pain presentation. Reveal aspect of the patient�s psychosocial history that are relevant to the current problem Define psychological and behavioral treatment strategies

5. Personality Disorders Definition: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual�s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood Kinney et al found that 60% of their sample of chronic patients met de diagnosis of personality disorders. Those disorder are particularly influential in a patient�s response to pain management and rehabilitation

6. The Dependent, Avoidant, Fearful Patient Evidence of clinical anxiety and nervousness, including hypervigilance, motor tension, pressured speech, and impatience Excessive dependence on physicians for continued guidance and support. Tendencies toward obsessive-compulsive behaviors such us persistent focus on diagnostic test results or medications Unfounded resistance to the use of medications These persons may be more open to acknowledging the role of psychological influences in their pain.

7. The Dramatic, Borderline, or Histrionic Patient Few or no objective findings to explain pain Often a female with a long history of problems with relationships Overly dramatic and excitable, labile emotions Possible attention-seeking behaviors such as exaggerated statements of pain or other physical problems Tendencies to demonstrate helplessness Tendencies toward numerous phone call to the physician, personal crises, and negative responses to treatment or interventions Tendency to �doctor shop�.

8. The Antisocial/Sociopathic Patient Usually little objective organic evidence for pain. Probable history of multiple injuries or claims History of violent or aggressive behavior History of �doctor shopping� or demands for changing physicians Frequent negative comments about prior treatment, physicians or case managers History of substance abuse, problems with legal system History of family problems Indirect or direct evidence of a history of malingering or manipulation of the healthcare system

9. The Somatoform Disorders Up to 75% of all visits to PCP involve manifestations of psychosocial problems in physical complaints The primary feature is the presence of physical symptoms that suggest a medical condition that cannot be fully explained by organic findings or known physiologic mechanisms There is usually evidence of a significant psychological component The production of physical symptoms and complaints is not a conscious and intentional act on the part of the patient

10. Somatoform Disorders Somatization Disorder ?Report recurrent and multiple somatic complaints for which medical attention has been sought. ?Symptoms have no clear relationship to any physical or medical disease ?Typically there is a combination of pain, GI symptoms, sexual dysfunction, and vague neurologic complaints ?Anxiety and affective symptoms are associated features

11. Somatoform Disorders Conversion Disorder Patients present with neurologic or other medical symptoms that suggest or reveal deficits in voluntary motor or sensory function. Symptoms are considered an expression of psychological conflict or need. Symptoms typically develop during times of particular psychological stress. Conversion disorder is not diagnosed when conversion symptoms are limited to pain. Most common symptoms are seizures, paralysis, coordination disturbance, blindness, and paresthesias.

12. Somatoform Disorders Pain Disorder Preoccupation with pain in the absence of physical findings that fully account for a cause or intensity of the pain. Pain is inconsistent with an anatomic distribution Psychological factors are judge to play a significant role in pain Patients often refuse to seriously consider that psychological factors might be influencing the clinical picture Symptoms of depression are common.

13. Factitious Disorders and Malingering Factitious disorders ?Are physical or psychological symptoms that are intentionally produced or feigned. ?External incentives for assuming a sick role, such as economic gain, work avoidance, or evading legal responsibility, are absent Malingering ?Intentional presentation of physical or psychological symptoms motivated by external incentives. ?Malingering is not considered a mental disorder. ?Should be suspected I there is a medicolegal litigation, lack of cooperation with diagnosis or treatment and with antisocial personality.

14. Affective Disorders Depression is the most common emotional disorder among patients with chronic pain Depression may occur as a reaction to pain or antedates the onset of pain. Can actually increase analgesic requirements Ask about suicidal ideas or specific plan to commit suicide A vicious cycle of pain, depression, and insomnia can develop, and patients often mistake emotional distress for pain.

16. Psychological/Behavioral Interview History and current subjective experience of the pain Conceptualization of the pain problem and treatment expectations Previous and current treatment and responses Behavioral analysis Vocational assessment and compensation and litigation status Social history Recent life stress Alcohol and substance abuse Assessment of psychological dysfunction.

17. Comprehensive Assessment Instruments Minnesota Multiphasic Personality Inventory (MMIP-2) ?Most widely instrument used in psychological assessment. ?Depressive symptoms have been identified in association with increased pain symptoms ?Intensity of depression has been found to be a significant negative predictor of treatment outcome. ?Patients with high score on somatization have had higher scores on pain-related disability ?Chronic pain patients frequently have elevations on scales of paranoia and/or schizophrenia.

18. Comprehensive Assessment Instruments The Battery for Health Improvement (BHI) ?It is a self-report inventory to identify factors that interfere with a patient�s normal course of recovery from a physical injury ?The test is helpful for workers� compensation patients because it gathers information about patient�s readiness for vocational training or job placement ?It is also helpful for evaluating emotional readiness for surgery

19. Comprehensive Assessment Instruments Pain Patient Profile (P-3) ? Effective instrument for briefly assessing for personality and psychological characteristics that are known to affect pain perception and treatment response of patients in pain ? A computerized profile is produced with an interpretation that compares the pain patient to a national sample of patients in pain. ? Symptoms of depression and somatization were significant predictors of medical and psychological factors that affected treatment outcome.

20. Conclusions Psychological assessment of the patient pain should include multidimensional evaluation and measures of compliance, motivation factors, and the social influences of pain on the patient