The Psychological Management of Chronic Pain by William W. Deardorff, Ph.D.

This is a beginning to intermediate level course. After taking this course, mental health professionals will be able to:

Introduction

Many disciplines provide psychological treatment of chronic pain patients. Some examples include psychology, psychiatry, clinical social work, nursing, medicine, and marriage and family counseling. In this online course, the term “pain management clinician” will be used to encompass practitioners in all of these fields.

Working with chronic pain patients requires a special skill set for the pain management clinician. One of the most important issues is to have a good understanding of current pain theories and the nature of the chronic pain syndrome since these form the rationale upon which psychological interventions are justified to the patient. The first chapter will provide an overview of a definition of pain, and different classification systems for pain, as well as outdated and current theories of pain.

Chapter 2 will present the various factors that can influence a patient’s perception of pain and overall level of suffering. The multi-factorial influences on pain will be reviewed including tissue input (nociception), pain sensation, thoughts, emotions, pain behaviors, and the psychosocial environment. Factors impacting the transition from acute to chronic pain will be discussed.

Chapter 3 will review a model for the biopsychosocial assessment of the chronic pain patient. This model is based upon a “targets of assessment” approach developed by Belar and Deardorff (1995, 2008). Methods of assessment for use with the chronic pain patient will also be presented including the clinical interview, questionnaires, patient diaries, psychometric testing, behavioral observation, and the review of archival data. A template for the chronic pain evaluation report will also be discussed.

Chapter 4 will present the most commonly used “direct” psychological treatments for chronic pain including cognitive-behavioral interventions and deep relaxation training.

Chapters 5 and 6 will review two common areas of “indirect” treatment in which the pain management clinician acts as a “consultant” to other healthcare professionals. In working with medical disorders, the pain management clinician must be comfortable interacting with the patient’s other providers (e.g., physician, physical therapist). This chapter will discuss the pain management clinician’s role in medication management and helping to design a physical rehabilitation program based upon behavioral principles.

Chapter One: Pain as Disease

This chapter will provide an overview of current theories of pain. The material will be presented in a straightforward and concise manner. The goal of this chapter is to provide the practitioner with an overview of the important concepts while also presenting the information in a manner that can be used when working with chronic pain patients. Giving the patient an understanding of the multi-factorial nature of chronic pain is essential to the success of any psychological intervention.

Chronic pain as disease: Why does it still hurt?

People who suffer from severe, chronic pain know how it can utterly disrupt and damage one’s life. Pain can be cruel, making it hard to enjoy even the simplest daily activities, and certainly making it a challenge to carry out an exercise routine and other healthy activities. Moreover, chronic pain was not previously that well understood. The medical profession used to believe that pain is always a manifestation of an underlying injury or disease. As will be discussed, it was also believed that the amount of pain correlated highly (almost one-to-one) with the amount of tissue damage or injury. As such, doctors focused on treating the underlying cause with the belief that once the injury or disease was cured, the pain would then disappear. If no underlying cause could be found, then the patient was told that very few treatments are available, or worse, “The pain must be in your head.” Unfortunately, some physicians still practice in this manner, having no appreciation for the unique problem of chronic pain, newer theories about pain, and the many factors that influence a chronic pain problem.

The medical community is starting to understand that if pain is no longer a function of a healthy nervous system (signaling that there is a disease or underlying injury), then the pain itself becomes the problem and needs to be treated as the primary pathology.

The experience of pain

To successfully treat a chronic pain patient, one must accept that all pain is real. This may seem like an obvious statement, but people with chronic pain are often treated as if their pain is either imaginary or exaggerated. Some of this is perpetuated by the mind-body dualism inherent in the medical model. Unfortunately, this model continues to be alive and well in the medical community. Mind-body dualism espouses the old dichotomy of “functional vs. organic” when evaluating and diagnosing chronic pain. In the model, functional pain is conceptualized to be of purely psychological etiology. A patient is often given this label by the physician if a precise reason for the pain cannot be found (identification of a pain generator). In this scenario, the psychological etiology is a diagnosis by exclusion. Given this situation, it is not surprising that many chronic pain patients feel like they have to prove their pain to their friends, family, and doctors. There are countless patients with stories of being told by doctors that there is no “medical” reason for the pain and therefore “it cannot be that bad.” One of the first tasks for the pain management clinician is to establish with the patient that his reports of pain will be believed. This is especially important since the patient may be hesitant about seeing a “shrink” in the first place. We will discuss this issue further under the initial interview section.

Working in this field is challenging because chronic pain is a somewhat unique medical problem. Pain is a personal experience and cannot be measured like other problems in medicine such as a broken leg or an infection. This causes a frustrating experience for the chronic pain patient in interacting with the healthcare system, family, and friends. Everyone knows that a broken leg can be confirmed by an x-ray and an infection by a blood test measuring the white blood cell count. Unfortunately, there is no medical test to measure pain levels. To make matters more challenging for the chronic pain patient, there may be no solid objective evidence or physical findings to explain the pain. Thus, chronic pain sufferers will go from one doctor to the next searching for medical explanations for their pain (and for a cure). This can lead to unnecessary evaluations and treatments, in addition to putting the patient at risk for actually being harmed or made worse by the interventions.

A Definition of Pain

Pain is not easy to define. In 1979, the International Association for the Study of Pain (IASP) published its first working definition of pain:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

This definition was reaffirmed in 1994 along with an extensive footnote discussion regarding its implications. The IASP definition acknowledges that, for most people, tissue damage is the “gold standard” by which pain is understood. However, the definition also recognizes that pain may occur in the absence of tissue damage and is impacted by emotional (psychological) factors. In the footnote explaining the definition, the authors point out that pain is not equivalent to the process by which the signal of tissue damage is passed through the nervous system to the brain (this is called “nociception” and will be discussed in detail later); rather, pain is always a psychological state that cannot be reduced to objective signs. In other words, pain is always subjective.

As shall be discussed later, the pain definition takes into account the following research findings:

Since pain is subjective, everyone experiences and expresses it differently. The IASP definition acknowledges research that has demonstrated that individuals with the exact same injury will feel and show their pain in unique ways depending on a number of things, such as:

The newest theories of pain can now explain, on a physiological level, how and why people experience pain differently. The newer pain theories will be discussed in detail later along with clinical and research findings about situational, cognitive, affective, and cultural influences on pain.

Categorizing Pain: Acute, Recurrent Acute, Chronic

Understanding how pain is categorized is critical to providing proper evaluation and treatment. The classification of pain is not a straightforward task and there is no one system that has been universally accepted by clinicians or researchers. As discussed by Gatchel (2004) and others (Turk and Melzack, 1992), there are many ways that pain can be classified, including:

Probably, the most common classification that is used is temporal. As Gatchel (2004) points out, this is likely due to the fact that the temporal classification best helps to understand the biopsychosocial contributors to the pain problem as well as guiding evaluation and treatment. However, it should be kept in mind that a simple temporal classification also has problems since it does not take into account acute recurrent pain (periodic acute pain episodes with pain-free periods in between) and tends to ignore pain conditions associated with a progressive disease process (cancer, COPD). For the purposes of this discussion, we will review the common temporal categories of pain along with modifications to take into account acute recurrent pain and pain associated with a disease process. In this schema, pain can be separated into acute, recurrent acute, and chronic. In addition, there will be sub-categories of chronic pain.

Acute pain

Acute pain is usually indicative of tissue damage and most often serves a protective function for the body by signaling potential physical harm. Acute pain can be defined as follows:

This is the kind of pain that you experience when you cut your finger or stick yourself with a needle. Other examples of acute pain are:

In acute pain, there is likely to be a one-to-one relationship between the amount of tissue damage and the pain experience. In addition, the pain will tend to subside in correlation with tissue healing. Acute pain is often associated with some anxiety that will motivate the individual towards adaptive and self-protective behavior (e.g., resting the injured body part during tissue healing, seeking medical attention).

Acute recurrent pain

In acute recurrent pain, the individual suffers from pain episodes with pain-free periods in between. The pain episodes are usually brief (less that 3 months) and associated with an identifiable physical process (such as migraine headache, sickle cell anemia, back sprain, etc.).

Chronic pain

In contrast to acute pain, chronic pain is usually less indicative of tissue damage, and generally does not serve a protective function for the body. A temporal definition of chronic pain is as follows:

As discussed previously, this definition emphasizing the temporal component is not completely adequate for all types of chronic pain problems. Even so, the psychological principles of chronic pain assessment and treatment remain the same. There are at least three types of chronic pain problems: (1) chronic pain that is due to a clearly identifiable cause or process, (2) chronic pain that is “nonspecific” and there is no clearly identifiable pain generator that explains the pain, and (3) chronic pain that is due to some type of nerve damage or abnormal nervous system reaction.

Chronic pain associated with a progressive disease

In chronic pain associated with a progressive disease, there is an ongoing disease process that is causing the pain. This might include such conditions as cancer, COPD, or muscle spasm in multiple sclerosis. These conditions are often actually categorized by disease state (e.g., cancer pain) which dictates special evaluation and treatment approaches.

Chronic non-cancer pain

Several terms have been developed for chronic pain in which a specific disease process or pain generator either cannot be identified or does not account for the level of pain and suffering being reported by the patient. These include chronic pain, chronic benign pain, chronic non-cancer pain, and chronic nonspecific pain. For the purposes of this discussion, we will simply use the term “chronic pain.” In this type of pain, the problem may have started with an acute injury or trauma (e.g., back injury) and developed into a chronic pain problem of more than 6 months duration such as chronic nonspecific low back pain or fibromyalgia.

It appears that pain can set up a pathway in the nervous system and, in some cases, this becomes the problem in and of itself. In this type of chronic pain, the nervous system may be sending a pain signal even though there is no ongoing tissue damage, or the tissue injury (pain generator) is less than what would be expected given the patient’s pain experience. The nervous system itself misfires and creates the pain. As we shall discuss, the pain signal from the peripheral nervous system is enhanced by higher-level central nervous system processes. In such cases, the pain is the disease rather than a symptom of an injury.

Chronic neuropathic pain

Neuropathic pain has only been investigated relatively recently; it seems to involve some type of direct injury to the nerves. In most types of neuropathic pain, all signs of the original injury are usually gone and the pain that one feels is unrelated to an observable injury or condition. With this type of pain, certain nerves (that have been injured or irritated) continue to send pain messages to the brain even after the initial tissue damage has healed.

Neuropathic pain (also called nerve pain or neuropathy) is very different from pain caused by an underlying injury. While it is not completely understood, it is thought that injury to the sensory or motor nerves in the peripheral nervous system can potentially cause neuropathy. Neuropathic pain is placed in the chronic pain category, but it has a different feel then chronic pain of a musculoskeletal nature.

Neuropathic pain feels different from musculoskeletal pain, and is often described with the following terms — severe, sharp, lancing, lightning-like, stabbing, burning, cold, ongoing numbness, tingling, and/or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet. Different types of neuropathic pain conditions include reflex sympathetic dystrophy (or Complex Regional Pain Syndrome), trigeminal neuralgia, postherpetic neuralgia, and radiculopathy.

Chronic Pain vs. Acute Pain

Unfortunately, many physicians still treat all pain as acute pain, using a unilateral medical model. Medical evaluation of acute pain might involve extensive diagnostic testing such as MRI, CT, and diagnostic nerve blocks to determine the cause of the pain (or “pain generator”). Treatment often includes medications, physical immobilization, invasive procedures, and surgery to try to correct the source of the pain. The medical approach is generally quite appropriate in acute pain cases (e.g., repair the bone fracture, torn muscle, herniated disc). However, this strictly biomedical approach can be exactly the wrong thing to do in cases of chronic nonspecific pain. In fact, treating nonspecific chronic pain as if it were acute pain will likely make the patient worse since it reinforces the sick role and subjects the patient to iatrogenic problems. Treating other types of chronic pain problems (progressive disease, neuropathies) strictly from a medical model is inappropriate. It is important to keep in mind that any type of chronic pain problem (and acute pain problem for that matter) is susceptible to the influence of psychosocial factors.

It is critical for the physician and patient to have an understanding of the difference between acute and chronic pain. Evaluation and treatment approaches will be different depending upon the type of pain problem.

Theories of Pain

Old ideas: The specificity theory of pain

René Descartes proposed one of the original theories of pain in 1664. He proposed that a specific pain system carried messages directly from pain receptors in the skin to a pain center in the brain. He suggested that it is like a bell-ringing mechanism in a church wherein a man pulls the rope at the bottom of the tower and the bell rings at the top. In this model, there is a one-to-one relationship between tissue injury and the amount of pain a person experiences. For instance, if you stick your finger with a needle, you would experience minimal pain whereas, if you cut your hand with a knife, you would experience much more pain. Thus, the specificity theory proposes that the intensity of pain is directly related to the amount of tissue injury. The specificity theory underwent modifications throughout the 19^th and early 20^th centuries, but its basic assumptions were unchanged (see Melzack and Wall, 1973, for a discussion of other pain theories including Muller’s doctrine of specific nerve energies, 1842; Von Frey’s theory, 1894; pattern theories from various theorists from 1894 through the mid-1950’s; Livingston’s central summation theory, 1943; and Noordenbos’ sensory interaction theory, 1959).

The specificity theory is generally accurate for acute pain, but it does not explain many types of chronic pain. Unfortunately, variations on the specificity theory are still taught (or at least emphasized) in many medical schools, and a majority of doctors still ascribe to it in practice. The theory assumes that if surgery or medication can eliminate the alleged “cause” of the pain, then the pain will disappear. In chronic pain cases, this is very often not true. If a doctor continues to apply the specificity theory to a chronic pain problem, the patient is risk for having surgeries, medicines and procedures that will not work as the search for the “source of the pain” presses on. Ultimately, the validity of the patient’s pain complaints will be challenged if reasons cannot be found and the “treatments” do not work.

Problems with the specificity theory

Several research findings and clinical observations have proven the specificity theory to be inadequate; these can be summarized as follows (see Wall & Melzack, 1973 and Turk & Gatchel, 2002 for more detailed discussions):

The meaning of the situation influences pain. Dr. Henry Beecher worked with severely wounded soldiers during World War II. To his surprise, Dr. Beecher observed that only one out of three soldiers carried into a combat hospital complained of enough pain to require morphine. Most of the soldiers either denied having pain from their significant injuries or had so little pain that they declined medication. These soldiers were not in a state of shock, and were able to feel pain inasmuch as they complained when the IV lines were placed.

When Dr. Beecher returned to his practice in the United States after the war, he noticed that trauma patients with wounds similar to the soldiers he had treated required morphine at a much higher rate to control their pain. In fact, four out of five patients required morphine for pain from wounds similar to those he had seen in the combat soldiers. Dr. Beecher concluded that this evidence demonstrated there was not a direct relationship between the wound and the amount of pain experienced. He believed the meaning attached to the injuries in the two groups explained the different levels of pain. To the soldier, the wound meant thankfulness to escape alive from the battlefield and to be going home. Alternatively, the injury to a civilian often meant major surgery, loss of income, loss of activities, and many other negative consequences.

Pain after healing of an injury. Another finding that discounted the specificity theory was that of phantom limb pain. Many times, patients who undergo the amputation of a limb continue to report sensations that seem to come from the amputated limb. This might include feeling that the limb is still there, or it may be a sensation of pain. Of course, the sensations cannot be actually coming from the limb since it has been removed from the person’s body. The specificity theory cannot account for these findings since there is no ongoing tissue injury in the missing limb.

Injury without pain and pain without injury. Injury without pain can occur in a variety of situations including individuals who are born without the ability to feel pain. These patients must learn to avoid damaging themselves severely since there is no “protective function” from pain. The following is just such a recent case (as reported on CNN.com Health, November 1, 2004):

If 5-year-old Ashlyn's chili is scalding hot, she'll gulp it down anyway. On the playground, a teacher's aide watches Ashlyn closely, keeping her off the jungle gym and giving chase when she runs. If she takes a hard fall, Ashlyn won't cry. Ashlyn is among a very small group of people in the world known to have congenital insensitivity to pain with anhidrosis, or CIPA -- a rare genetic disorder that makes her unable to feel pain. The untreatable disease also makes Ashlyn incapable of sensing extreme temperatures -- hot or cold -- disabling her body's ability to cool itself by sweating. The genetic mutation that causes CIPA only disrupts the development of the small nerve fibers that carry sensations of pain, heat, and cold to the brain.

Another fairly common situation is a person being distracted when injured such that pain is not felt. In this case, it is not unusual to hear stories of accident victims presenting to the emergency room stating they were injured (including major lacerations of the skin and fractured bones) but did not experience pain until minutes or hours afterwards.

Pain without injury or after the point of complete tissue healing can occur in a number of medical conditions such as central neuropathic pain after a stroke, reflex sympathetic dystrophy (complex regional pain syndrome), phantom limb pain, and post-herpetic neuralgia.

Hypnosis for anesthesia. The specificity theory cannot explain how hypnosis can be used for anesthesia during surgery. Certain people under hypnosis can withstand high levels of pain that would normally cause them to cry out. Surgery has been done on almost every part of the body using only hypnosis for anesthesia. Obviously, significant tissue damage is occurring during the surgery but the patient under hypnosis is not experiencing any pain. This finding dealt the specificity theory its final blow.

New Ideas: The Gate-Control Theory of Pain

Due to the findings listed above, a new theory of pain was developed in the early 1960’s that could explain these results. It is called the gate control theory of pain, and it was developed originally by Melzack and Wall (1965). The gate control theory changed the way in which pain perception was viewed. The original theory is very complex and a detailed discussion is beyond the scope of this presentation. However, it is valuable to present an overview of the theory in language that can be used with patients. Explaining the basics of this theory to patients can help establish the credibility of psychological pain management interventions. It will also demonstrate to the patient that the psychological intervention can actually change (decrease) the experience of pain on a physiological level.

The gate control theory attempts to explain the experience of pain (including psychological factors) on a physiological level. Based upon subsequent challenges and findings, the original gate control theory has undergone some reformulation and revision, but the basic tenets hold true. It has been able to explain a variety of pain phenomena and has had enormous heuristic value in stimulating further research (Turk and Flor, 1999).

In the gate control theory, pain is divided into two components that are processed separately by the body. These are:

Pain messages flow along the peripheral nerves to the spinal cord and proceed to the brain. In the spinal cord, there are “nerve gates” (in the dorsal horn substantia gelatinosa) that can inhibit (close) or facilitate (open) nerve impulses going from the body to the brain. These nerve gates are influenced by a number of factors including the diameter of the active peripheral fibers converging in the dorsal horns as well as “instructions” coming down from the brain.

The relative excitatory activity in the afferent large-diameter (myelinated) and small-diameter (unmyelinated) nociceptor fibers is thought to influence the spinal gates. The activity in the A-beta (large diameter) is thought to primarily inhibit transmission (close the gates) whereas the A-delta and C (small diameter) activity are thought to primarily facilitate transmission (open the gate). When the gates are more open, a person experiences more pain since the messages flow freely. When the gates close, the pain is decreased or may not be experienced at all. The specifics of each part of the pain system are discussed in the following paragraphs. These are important concepts because they explain why certain treatments are effective.

The peripheral nervous system

This will be a brief review of your graduate course in psychophysiology. Sensory nerves bring information to the spinal cord from various parts of the body. These nerves are specialized to detect pain, heat, cold, vibration, and touch. At least two types of small diameter nerve fibers are thought to carry the majority of pain messages to the spinal cord:

As discussed earlier, the activity of the A-delta and C fibers tend to facilitate transmission of the nerve impulse (“open” the spinal nerve gates). In addition, they result in a different pain sensation. A good example of how these different nerve fibers work is when you strike the “funny bone” in your elbow (actually the ulnar nerve). You may notice that the first sensation is a sharp, tingling pain followed by a second sensation of achiness. The first sensation is the activation of the A-delta nerve fibers followed by the activation of the slower C fibers. The activation of different nerve fibers can produce different qualities of pain sensation.

Also, you may have noticed that when you strike your elbow or hit your head, rubbing the area seems to provide some relief. This is because you are activating other sensory nerve fibers. These nerve fibers carry pressure and touch messages to the spinal cord:

These speeding messages can reach the spinal cord and brain to override some of the pain messages carried by the A-delta and C fibers. When this overriding occurs, the pain messages are decreased and you experience less pain. The action of these differing nerve fibers can explain why many treatments for pain are effective. Treatments such as massage, heat, cold, TNS (transcutaneous nerve stimulation), or acupuncture can change a pain message due to some of these differences in nerve fibers.

The spinal cord

The pain message travels along the peripheral nervous system until it reaches the spinal cord. At this point, an extremely complex system can:

As discussed previously, the gate control theory proposes that there are gates on the bundle of nerve fibers in the spinal cord between the peripheral nerves and the brain. These spinal nerve gates can either open to allow pain impulses to move freely from the peripheral nerves to the brain, or they can close to stop the pain signals from reaching the brain. Many factors determine how the spinal nerve gates will manage the pain signal including:

The brain

Once the pain signal reaches the brain, a number of different things can happen. Certain parts of the brain stem can inhibit or muffle incoming pain signals by the production of endorphins, which are naturally occurring morphine-like substances. Stress, excitement, and vigorous exercise are among the things that may stimulate the production of endorphins. This is why athletes may not notice the pain of a fairly serious injury until the “big game” is over. This is also why regular aerobic exercise can be an excellent method to help control chronic pain.

In addition, pain messages may be directed along different pathways in the brain. For instance, a fast pain message is relayed by the spinal cord to specific locations in the brain—the thalamus and cortex. A fast pain message reaches the cortex quickly and prompts the individual to take action to reduce the pain or threat of injury.

In contrast, chronic pain tends to move along a “slow pain” pathway. As discussed above, slow pain tends to be perceived as dull, aching, burning, and cramping. Initially, the slow pain messages travel along the same pathways as the fast pain signals through the spinal cord. Once they reach the brain, the slow pain messages take a pathway to a different portion of the brain, the hypothalamus, and the limbic system. The hypothalamus is responsible for the release of certain stress hormones in the body. The limbic system is the brain area where emotions are processed. As shall be discussed later, this is one reason why chronic pain is often associated with stress, depression, and anxiety. The slow pain signals are actually passing through brain areas that control these experiences and emotions.

As discussed earlier, the brain also controls pain messages by attaching meaning to the situation in which the pain is experienced. This occurs in the cortex, which is a higher level of the brain where thinking takes place. As reviewed previously, soldiers who were wounded in combat displayed much less pain then similarly wounded civilians who had been involved in a trauma such as a car accident. The meaning that the brain attached to the situation seemed to be the important difference. The brain also gives meaning to the pain signal; this occurs in the cortex. Depending on how the messages are received and other factors related to the situation, the brain might pay close attention to the pain signal, or choose to ignore it altogether.

Down the Pain Pathways

So far, we have primarily focused on factors that influence the pain signal as it travels from the periphery to central structures (afferent input). In addition to these influences, the pain signal can be influenced by efferent neural impulses that descend from the brain. In other words, the brain can send signals down the spinal cord to open and close the nerve gates. At times of anxiety or stress, the descending messages from the brain may actually amplify the pain signal at the nerve gate as it moves up the spinal cord. On the other hand, the descending message from the brain can “close” the nerve gate in the spinal cord and the message will be stopped at the closed nerve gate (no pain experienced by the brain). This can occur in situations such as being in battle, playing competitive sports, being under hypnosis, or being distracted.

Opening and closing the pain gates

In working with chronic pain patients, it is important to carefully explain the gate control theory of pain along with providing examples. This creates an excellent foundation for discussing what factors can open and close the spinal nerve gates. The following presentation can be helpful for patients:

Let's look at a number of other things that can open or close the pain gates as messages move up and down the spinal cord. These can be divided into sensory, cognitive, or emotional areas.

Sensory factors include things that are related to your actual physical being and activities.

Cognitive factors are those things that are related to your thoughts. This might include your memories, your interpretation of a current situation, or your predictions about the future.

Emotional factors are those things related to your emotions or feelings. Emotions are being happy, sad, mad, or glad.

Sensory factors are such things as injury, inactivity, long-term narcotic use, poor body mechanics, and poor pacing of your activities.

Cognitive factors are focusing on the pain, having no outside interests, worrying about the pain, remembering bad things associated with the pain, and thinking that your future is a catastrophe.

Emotional factors include depression, anger, anxiety, stress, frustration, hopelessness, and helplessness.

Sensory factors can include increasing your activity, short-term use of pain medication, relaxation training and meditation, and aerobic exercise.

Cognitive factors include outside interests, thoughts that help you cope with the pain, and distracting yourself from the pain.

Emotional factors that can close the pain gates include having a positive attitude, decreasing depression, being reassured that the pain is not harmful, taking control of your pain and your life, and stress management.

The following illustration is helpful for patients to understand the gate control theory of pain.

Patient examples: The gate control theory in action

The following examples can be presented to patients to help illustrate two things—(1) how the brain can selectively block out sensations it perceives as non-threatening, and (2) the gate control theory in action:

You may notice that when you first get dressed, you can feel the physical sensations that result from the clothing. This is especially true for the typically tighter fitting items such as underwear and shoes as they press against your body. After you have had your clothes on for even a brief period of time, the physical sensations are not noticeable at all unless you specifically pay attention to them. This is an example of how the brain blocks out sensations that it knows are not dangerous.

The next two examples relate directly to pain problems. Imagine that a tight clothespin has been placed on your arm and you are instructed to leave it there for the entire day. For those of you with masochistic tendencies, go ahead and try this experiment for yourself rather than just using your imagination. The initial pain from the tight clothespin might be quite severe as it compresses your skin and surface muscles. Peripheral nerve fibers sense this pressure and transmit a pain signal to the spinal cord and on to the brain. At first, you'll notice a fast pain, but after a while you may notice a slow pain. The pain is initially experienced as fairly proportional to the amount of pressure applied. Everyone would agree that this is acute pain.

After a short while, the pain messages coming from the clothespin will begin to be decreased by the closing of the spinal nerve gates. This is because the brain begins to view the pain signals as non-harmful and not a threat. The pressure from the clothespin may be painful at first, but it is not injuring you in any way. As time goes on, the pain message is given less priority by the brain and your awareness of it decreases greatly. The brain knows that the clothespin will be there all day long and it is not causing any injury. Therefore, the brain gradually “turns the volume down” on the pain message to the point of it being barely noticeable after about thirty minutes. The compression on your skin is still occurring, but it is now perceived as either a mild discomfort or not noticed at all.

The last example is one that occurs at our spine institute almost on a daily basis. Just recently, a female patient came in convinced that her back pain was due to a spinal tumor. A thorough physical examination and medical history was entirely normal except for the onset of the back pain after a recent period of extreme stress. The stress involved the patient’s elderly father who had recently been diagnosed with (you guessed it) a spinal tumor. The patient reported that her father’s symptoms had also initially been back pain. Upon questioning, it became quite clear that the patient had an extreme fear that she also was suffering from a spinal tumor. This belief was creating intense suffering which, in turn, made the back pain worse. An MRI was obtained and shown to be negative, and the diagnosis above, stress related back pain, was made. After experiencing tremendous relief that the back pain was not the result of a tumor (in addition to one or two jumps of joy), the patient’s symptoms began to dissipate rather rapidly, and she returned to normal activities.

When Acute Pain Becomes Chronic

Not all pain that persists will turn into chronic pain. Pain is experienced very differently for different people. Likewise, the effectiveness of a particular treatment will often differ from person to person. For example, a certain medication or injection for a herniated disc may provide effective pain relief for some people but not for others.

Not all patients with similar conditions develop chronic pain, and it is not understood why some people will develop chronic pain and others will not. In addition, a condition that appears relatively minor can lead to severe pain, and a serious condition can be barely painful at all.

As pain moves from the acute phase to the chronic stage, factors other than tissue damage and injury come more into play. Also, influences other than tissue input become more important as the pain becomes more chronic. These include such things as ongoing “pain” signals in the nervous system even though there is no tissue damage, as well as thoughts and emotions. This can be a difficult concept for chronic pain patients to accept. A common retort is, “But my pain is real.” Remember, as we discussed at the beginning of this section, all pain is real and physically experienced. However, the gate control theory establishes that pain can be affected by a variety of factors other than tissue input. After a discussion of the gate control theory and some of these examples, patients are often more open to accepting the idea of psychological pain management treatment.

Chapter Two: Chronic Pain and Suffering

“Those who have something better to do don't suffer as much.” – W. Fordyce, Ph.D.

Many things can increase or decrease a patient’s perception of pain. These influences on pain perception are explained by the gate-control theory. This section will be a further discussion of these issues, as it is a commonly neglected topic in traditional approaches to chronic pain. These factors are well known to the research and academic communities but rarely acknowledged in general practice. The concepts presented in this chapter are excellent to discuss with chronic pain patients.

The Pain System

As explained by the gate control theory of pain, there is not a one-to-one relationship between tissue damage and pain. Rather, many factors influence chronic pain, disability, and suffering. Thus, a person can have severe pain with minimal physical findings and minimal pain with horrendous physical findings. The “onion” model pictured subsequently describes in a simple format what is currently known about aspects of chronic pain. The model makes common sense given the examples discussed in the previous chapter such as hypnosis and phantom-limb pain. In using this model with patients, the importance of addressing all aspects (or “layers”) of the chronic pain problem can immediately be understood. The following are definitions of the various "layers" of pain in the model:

This diagram depicts the pain system and the various influences on chronic pain. Tissue damage is only one of many factors determining how much pain will be experienced. This pain system model is excellent for use in working with chronic pain patients.

The Multi-factorial Nature of Pain and Suffering

Tissue damage or nociception

Nociception is defined as mechanical, thermal (heat or cold), or chemical energy acting on specialized nerve endings that send an impulse, or "signal," into the nervous system that negative events are occurring. The “transduction” of tissue trauma into neural signal depends upon sensory end organs known as nociceptors (Chapman, Nakamura, & Flores, 1999). Nociceptors are sensory neurons found throughout the body. As discussed previously, these nociceptors consist of:

Both of these types of fibers are distributed widely in skin and deep tissues. These nociceptors are usually the beginning point of the "pain" message. Pain is produced by repetitive stimulation of these receptors. It might include an impact or trauma (mechanical, such as cutting yourself), an injury involving temperature (thermal, such as burning yourself), or an injury involving chemical changes (chemical, such as an irritant). Nociception is what occurs at the site of injury that usually leads to pain being experienced. For instance, if you have ever hit your finger with a hammer or struck your toe on a table, you may have noticed that the pain signal can take a brief moment to reach your brain and be experienced.

Pain sensation

In the simplest terms of this model, pain is the actual perception that occurs in the brain after the nerve signal (due to nociception) travels from the periphery to the central nervous system. Pain sensation is experienced in the brain, while nociception occurs at the site of injury. However, it must also be kept in mind that a pain sensation can be experienced without nociception as discussed in the last section on phantom limb pain. In addition, there may be no pain sensation even with extensive nociceptive input (e.g., the severely wounded soldier or surgery under hypnosis).

Thoughts

Cognitions or thoughts occur in higher brain centers and are an assessment of the pain-sensation signal coming into the nervous system as well as events surrounding it. These thoughts can be conscious or unconscious and will greatly influence how the pain signal is perceived. For instance, general body aches and stiffness are perceived as "good pain" when these occur after a vigorous exercise session, whereas they are perceived as "bad pain" when related to a medical condition, such as fibromyalgia. The level of actual input to the nervous system may be the same, but the thoughts about the input cause the pain in the patient with fibromyalgia to be perceived as much more distressing.

Another example was experienced by this author. As a teenager he was struck in the face by a door, causing a significant injury with profuse bleeding that required forty stitches. Interestingly, no pain was experienced until the extent of the injury was realized by seeing the reaction of others and looking in the mirror. After that, the pain became quite intense. These examples illustrate how thoughts (conscious and unconscious) impact pain perception and suffering. The thoughts were generally of the nature, "Oh, this must be very serious!" which made the pain worse.

In the case of chronic back pain (and other chronic pain conditions), a similar assessment of the situation occurs in the patient. Many patients are convinced that their chronic pain represents serious damage even though physical findings are minimal. They believe that hurt equals harm, and are totally guided and controlled by the pain. In these people, suffering is very great. Alternatively there are people (a smaller group by far) who have very severe findings on their diagnostic tests (e.g., MRI, CT of the spine) yet who don't seem to be bothered by the pain. They perceive their pain as benign or not dangerous. They live their lives regardless of the pain, and overall suffering is thereby diminished. Thus, these differences in pain sensation can be explained by differences in thoughts and attitudes about the pain.

Changing a patient’s thoughts about her chronic pain is one of the most powerful psychological treatment tools; this will be discussed in the chapter on cognitive behavioral interventions.

Emotions

The emotional aspect of pain is a person’s response to thoughts about the pain. If you believe the pain is a serious threat (thoughts), then emotional responses may include fear, depression, or anxiety. Conversely, if you believe the pain is not a threat, then the emotional response will be negligible. Consider again the previous example of a strenuous workout. The day afterward, the person may show grimacing, slow movements, and other "pain behaviors." Even so, the thoughts about the pain will be positive ("Boy, what a good workout that was last night") and the emotions will follow similarly (e.g., feeling good about having worked so hard). The thoughts and subsequent emotional response would be quite different in the case of a fibromyalgia flare-up even though the nociceptive input and pain behaviors are similar. We will discuss the emotional aspects of pain in more detail later in this chapter.

Suffering

Suffering is very closely tied to the emotional aspect of pain. In general, it is triggered by aversive events, such as loss of a loved one, fear, or a threat to one's well being. Suffering very often occurs in anticipation of a possible perceived threat even though the threat may not actually exist. A very good example of this last scenario was presented in the previous section (the back tumor example). A patient with severe headaches was firmly convinced she had a brain tumor. Her husband had recently died of a brain tumor that had started with simple headaches. Her suffering was very high because she was anticipating her headaches were a sign of a very serious condition that could lead to death. After the MRI, it was confirmed that she did not have a tumor and that her headaches were likely due to muscle tension. Her suffering decreased significantly, as did her pain. This illustrates extreme suffering in response to a threat that never actually existed. It also illustrates how a patient’s level of suffering can change even when the nociceptive input and pain sensation do not.

Pain behaviors

Pain behaviors are defined as things people do when they suffer or are in pain. The behaviors that others observe as typically indicating pain include:

Pain behaviors are in response to all the other factors in the pain system model (tissue damage, pain sensation, thoughts, emotions, and suffering). Pain behaviors are also affected by previous life experiences, expectancies, and cultural influences in terms of how the pain is expressed. Interestingly, pain behaviors are also affected by the outside environment, as will be discussed in the next section.

Psychosocial environment

Psychosocial environment includes all of the environments in which we live, work, and play. Research has consistently shown that these environments influence how much a person will show pain behaviors. One might also expect that pain behaviors will vary across the different psychosocial environments of the patient. Chronic pain can affect all aspects of a person's life including relationships, work activity, sexual functioning, and recreational pursuits. Exactly how these environments can affect the patient’s pain and suffering are important to evaluate since this can help guide the treatment intervention.

Factors Influencing Acute and Chronic Pain

As we discussed in the previous section, pain can generally be divided into acute and chronic phases based upon the length of time in pain and how fast the tissues are expected to heal. It is very important to understand that as pain moves from the acute to the chronic stages, the influences of other factors in the pain system (aside from tissue damage) come more into play. Gatchel (1991, 1996, 2004) has characterized this progression from acute to chronic pain as a three-stage model. This is illustrated in the following figure:

This model can be applied to a number of chronic pain problems, especially those of a musculoskeletal nature. As can be seen in this model, as the pain goes on longer and longer, factors other than tissue input become more influential. This can be a difficult concept for patients to understand, and the common retort is, "But I have real pain." Again, as a reminder, the pain is absolutely real and is physically experienced. It is simply being supported and increased by factors other than the tissue damage. Another conceptual model of the various factors influencing acute versus chronic pain is as follows:

As we discovered in the pain system model, thoughts, emotions, and suffering are an integral part of any chronic pain experience. In this section, we will further investigate how emotions influence pain and vice-versa. These emotions include depression, anxiety, fear, and anger.

Chronic pain and depression

Comorbid psychiatric disorders commonly occur in chronic pain patients and, among these, depression is frequent. Chronic pain and depression are two of the most common problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004). For instance, major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. These range from 32 to 82 percent of patients showing some type of depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study of chronic disabling occupational spinal disorders in a large tertiary referral center, the prevalence of major depressive disorder was 56% (Dersh, Gatchel, Mayer et al., 2006). In another study, it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either condition alone.

Depression is more commonly seen in chronic back pain problems than in those pain problems of an acute, short-term nature. The development of depression in these cases can be understood by looking at the host of symptoms often experienced by the person with chronic spine pain. Explaining this process to the patient can be very useful since it demystifies the etiology of the depression and dispels the idea that being depressed is somehow related to a “weak will.” We will often tell patients that clinical depression goes beyond normal sadness, and is characterized by the following symptoms from the DSM-IV:

It is often quite impactful to go over this list with the chronic pain patient since it can help develop a therapeutic alliance in treating the depression.

Chronic pain often results in difficulty sleeping which leads to fatigue and irritability during the day. During the day, the chronic pain patient often has difficulty with most activities (moving slowly and carefully) as well as spending most of the time at home away from others. This leads to social isolation and a lack of enjoyable activities. Due to the inability to work, there may be financial difficulties that begin to affect the entire family. Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications. The pain is distracting, leading to memory and concentration difficulties. Sexual activity is often the last thing on the person’s mind; this causes more stress in the relationships. Understandably, these symptoms accompanying chronic pain may lead to feelings of despair, hopelessness, and other indicators of a major depression.

A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including physical limitations that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses. Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often lead to depression and anger among the back pain patients, and to stress and strain in family relationships.

Several psychological theories about the development of depression in chronic back pain focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends. This situation leads to a downward physical and emotional spiral that has been termed “physical and mental deconditioning” (as depicted in the previous Figure; see Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to a major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist.

Depression and chronic pain

The heading above is not a typo. We first discussed chronic pain leading to depression, and now we will now cover the idea that depression can predispose a patient to chronic pain.

For quite some time, clinical researchers have known that chronic back pain can lead to major depression (see Worz, 2003 for a review). Newer studies are now looking at how psychological variables such as depression and anxiety may be linked to the onset of a back and other pain problem. For example, Atkinson, Slater, Patterson, Grant, and Garfin (1991), in a systematic study of depressed male Veterans Administration chronic pain patients, found that 42% of patients experienced the onset of depression prior to the onset of pain, whereas 58% experienced depression after the pain began. Polatin et al. (1993) reported that 39% of the chronic low back pain patients they evaluated displayed symptoms of preexisting depression. More recently, in a review of research studies in this area, Linton (2000) found that ,in 14 of the 16 reviewed studies, depression was found to have increased the risk for developing back pain problems.

Depression and Spine Surgery

As we have seen, many chronic pain patients will experience clinical depression. In addition, these patients will also be faced with the option of elective surgery in an attempt to help the pain. Having some understanding of the impact of depression on surgery is important. The following material will briefly address this issue relative to back pain and spine surgery; however, the conclusions are generalizable to other chronic pain states.

Research has clearly demonstrated that nonphysical variables such as depression, anxiety, thought patterns, and personality style can influence a spine surgery outcome (see Block, Gatchel, Deardorff & Guyer, 2003 for a review). Unfortunately, it appears that in many cases, having a major depression may not bode well for the outcome of a spine surgery. For instance, as discussed by Block et al. (2003), spine surgery patients who are clinically depressed preoperatively may continue to display depressive symptoms post-operatively; moreover, this can negatively affect the surgery outcome. Particular symptoms that may impede postoperative recovery include such conditions as low motivation, sleep disturbance, slower healing time, difficulty with physical rehabilitation and inability to perceive improvements (Block et al, 2003; Deardorff and Reeves, 1997).

Block et al. (2003) discuss that, in looking at the issue of depression and spine surgery outcome, it is important to consider if the individual is experiencing a “reactive depression” or shows a pre-injury history of more chronic depression. A reactive depression is defined as depressive symptoms in response to the chronic back pain and associated problems (loss of work, friends, etc.). Reactive depression occurs in back pain patients who have no previous history of depression. However, many chronic back pain patients have a history of problems with depression even before the onset of the back pain. As reviewed previously, individuals with chronic depression may be at greater risk for developing a low back pain condition. It is also likely that this same group is at greater risk for a poorer outcome to spine surgery (Block et al., 2003).

If you are working with a chronic pain patient with significant depression who is facing an “elective” surgery for her pain problem, you may want to recommend (to patients and surgeon) that consideration be given for postponing the surgery until the depression can be treated. Treatment for depression is often part of a preparation for spine surgery program (see Block et al., 2003; Deardorff and Reeves, 1997).

Treating depression in the chronic back pain patient

One of the biggest problems in treating major depression in the patient with chronic pain is missing the diagnosis. This occurs for two reasons—the chronic pain patient often does not realize he is also suffering from a major depression, and the doctor is not looking for it. Chronic pain patients will often define their problem as strictly medical and related to the pain. This is supported by a recent study, which found that individuals with chronic pain and depression went to their physicians 20% more often than a comparison group of non-depressed medical patients. In addition, depressed chronic back pain patients were 20% less likely to see a mental health specialist than medical patients without a pain problem (Bao, Sturm, & Croghan, 2003).

The depressive symptoms may be downplayed by the chronic pain patient who believes that, “just get rid of this pain and I won’t feel depressed,” or that acknowledging depression is a sign of weakness in dealing with the pain. When the diagnosis of major depression in the chronic pain patient is missed or ignored, treatments strictly directed at the pain are much more likely to fail. As concluded by Ohayon and Schatzberg (2003), the presence of a chronic pain physical condition increases the duration of depressive mood; chronic pain patients seeking medical consultation should be routinely screened for a major depression.

Treatment of depression associated with chronic pain requires a specialized approach. It is generally accepted that the pain and the depression should be treated simultaneously in a multidisciplinary fashion. The treatment of clinical depression most often includes psychological interventions (e.g., counseling, relaxation training) and antidepressant medication. In a recent review of the research from 1980 though 2000 looking at treatment of depression, it was found that the combined treatment approach (medication and psychotherapy) yielded better outcomes than either of the interventions alone (Pampallona et al., 2004). Simultaneous treatment directed at the chronic pain is critical. It has been found that chronic pain may interfere with depression improvement; this makes common sense. Treatment for the chronic pain might include such things as physical rehabilitation aimed at restoration of function, trying to “normalize” one’s life as much as possible even with the pain, and appropriate medication management. Multidisciplinary treatment of the chronic pain and major depression will ultimately give the patient more of a sense of control over the pain, and start a “positive spiral” toward physical and mental reconditioning.

Anxiety

In most cases, anxiety about the pain is more likely in the subacute stage while depression prevails with chronification. The subacute phase occurs after the acute phase but before the chronic stage. It usually occurs at about the three- to six-month range. At the acute stage, the patient with pain generally feels a reasonable sense of hope that the pain will resolve within the near future. In the subacute phase and at the beginning of the chronic phase, one's thoughts and emotions about the pain begin to change. It is not uncommon for the person to begin to wonder, "Will this pain ever go away?" "This must be something serious," and "I'll never get better." These types of thoughts lead to anxiety.

Anxiety can occur at different intensities, all the way from nervousness to full panic attacks. We explain to patients that clinical anxiety is generally characterized by the following:

Although most patients believe that their anxiety will subside "when the pain goes away,” the anxiety is very often causing a significant increase in pain perception. This results in a vicious cycle of pain, anxiety, more pain, and more anxiety. As an example of this, this author recently evaluated and treated a seventy-two-year-old woman who had been scheduled to undergo spine surgery. She was clearly a good candidate for the surgery given all appropriate factors. As one part of her pain problem, she had a significant amount of generalized anxiety. She had been involved in a few sessions of psychological preparation for surgery, which we will often do with anxious or depressed patients. Approximately two weeks prior to the scheduled surgery, the patient's leg pain completely disappeared! Her findings on the MRI continued to be abnormal. The surgeon could only explain it under the category of "an act of nature one does not want to argue with." Given this experience, the patient expected that her anxiety and depression would also abate shortly thereafter. To her dismay, this did not occur. She continued to be emotional and began to address those issues in psychotherapy.

This is certainly an unusual and rare example, but it does illustrate that removal of the pain does not necessarily mean emotional issues will also then resolve. For the patient to wait until the chronic pain is gone before addressing emotional issues is a trap that will prevent a return to a normal life.

Fear and phobia

Recent research suggests that fear may be a significant component in many types of chronic pain. This is usually focused on the fear of further injury, increased pain, or both. This fear is often closely linked with the anxiety discussed in the previous section.

Fear in chronic pain is unreasonable when it is either not appropriate to the situation or is beyond what it should be, given the nature of the situation. This might include being fearful of reinjury when there is no indication that this will occur. When fear is at these levels and interferes with normal functioning, it is considered a phobia. A phobia is defined as an irrational fear of an object, activity, or situation causing the person to avoid the object, activity, or situation (e.g., movement).

A new area of scientific investigation in many types of chronic pain is “kinesophobia,” or fear of movement. In our clinical practice, we see kinesophobia quite routinely. These patients have guarded, slow, and deliberate movements, as well as extreme cautiousness. This is often due not to the pain but rather to a phobia of injury, reinjury, or acute exacerbation. The following case example illustrates this condition:

The patient was a forty-two-year-old man who was a very successful lawyer. He had one episode of fairly severe back pain, somewhat localized, which lasted for quite some time. He attributed the onset of the pain to "moving a certain way" while getting out of his car. This had occurred about four months prior to the patient coming to our clinic. In that time, he had been seen by several specialists, at least one of which had recommended spine surgery. The patient came in with extremely slow, almost robot-like movements in an attempt to keep his spine as straight as possible. Out of fear of making the pain worse, he would not bend. He had developed a very structured ritual in order to get dressed each morning. This included putting his underwear and pants on the floor, stepping into them, and then gradually working them on with the help of a reaching device. He had developed similar rituals for putting his shoes on, driving, working at his desk, and interacting with his children. We ultimately involved him in an aggressive physical therapy program for reactivation and mobility as well as psychological pain management to address his kinesophobia. We even employed such unusual techniques as having him do a type of obstacle course through the gym with a time clock so that he could not focus on his fear of the pain. There was no medical reason for him to fear the pain or to be a surgical candidate. The patient responded very well to the program with a return to normal activities.

Kinesophobia can cause great problems over the long term. The fear of movement results in the patient attempting to move as little as possible. This guarding behavior causes the muscles in the back to fall into a state of disuse and atrophy. The muscles become weak and tight (shortened) due to lack of use. Any attempt to increase activity will then cause an increase in pain due to the weak and tight muscles. This scares the patient into not doing anything. Working through this period of increased pain under supervision with reassurance is critical to recovery from the pain problem.

Development of the disuse syndrome and physical/mental deconditioning due to fear of injury and pain. The cycle causes more and more pain to occur as can be seen in the Figure.

Anger

Anger is frequently an integral component of chronic pain problems. It is helpful to explain to patients that anger may be felt and expressed directly or indirectly. We are all familiar with the direct expression of anger. This might include such things as a short temper, irritability, and explosive behavior. Indirect anger may be expressed in a number of ways. For instance, depression has been defined as "anger turned inward" and may, in some cases, be a type of indirect anger. We often see chronic pain cases where there is no overt anger but an increase in self-destructive behaviors, such as increased smoking, coffee intake, risk taking, and substance abuse (alcohol and/or medicines). These patterns can indicate indirect anger. Another expression of indirect anger is passive aggressiveness. This is anger expressed outwardly but in a passive, indirect manner. It is important to investigate how the patient might be using pain and disability in a passive aggressive manner. An example of this includes an increase in pain (or pain behaviors) in response to someone with whom the patient is actually angry. We commonly see this pattern in marital or family relationships. Usually, the person with chronic pain who is expressing anger through increased pain does so unintentionally and is not aware of the pattern. Consider the following case example:

We once treated a man with chronic low back pain who had not responded to the usual conservative interventions. As part of the multidisciplinary program, he became involved in pain management treatment with a psychologist. As part of these treatment sessions, the spouse is often brought in to help determine how the family is responding to the pain problem. Initially the couple stated that they "rarely fight" and that the pain problem had not really bothered them that much. This was in the face of also reporting that the man had been disabled from work, they had not had sex in over six months, and that she had had to get a job to help support the family due to his disability.

As the treatment progressed, it became clear that there was a high degree of anger in both of them that was not being expressed directly. The husband would show an increase in pain behaviors in response to any possible area of conflict in the marriage. For instance, the wife once attempted to discuss their financial status in the session. He eventually started having more and more trouble with his back pain as the discussion progressed, to the point of having to stand up and walk around the clinic. He also felt, that, whenever she did bring up the topic of finances, she was implying that he was bringing all this misery to the family on purpose. In contrast, she stated she was simply trying to "brainstorm" about how to realistically manage their finances. She would also express her anger at the situation indirectly. At first, she was very supportive in helping with more responsibilities around the house due to his pain problem. However, as the pain went on and on, she became more frustrated with the situation. She started to spend more and more time away from home, and away from him. He began to respond to this by unconsciously showing more pain behaviors in order to try to get her attention once again. Of course, this drove her farther away. The cycle was becoming worse and worse until the issue was openly discussed in the pain management sessions.

Entitlement

Another aspect of anger in chronic pain is that of entitlement. This is a term for the feeling that "somebody or something owes me something for the pain that I am experiencing”. We often see this sense of entitlement in cases where the chronic pain has started as the result of a work-related injury, or car accident. People commonly feel they are "entitled" to a pain-free existence and that any limitation of normal activities due to pain is unacceptable. They feel that if their lives are disrupted or limited in any way due to pain, then "somebody should pay." Although in a legal sense this might in part be accurate, from a psychological perspective this attitude can be very self-destructive.

When a patient has excessive focus on what she is "entitled to" due to the pain, it will generally prevent her from taking responsibility for getting better. When there is litigation involved, the situation becomes even more complex, as we shall see in the next section. Even when there is not litigation involved, human beings will naturally look for a place to "put the blame" for their pain. We do this in an attempt to explain the pain and to direct our anger at something. This blaming may be directed at a spouse, at doctors who were unable to find a reason for the pain or provide a cure, "the guy who hit me," "the idiot who left a slippery floor for me to fall on," or "God, for putting me in this painful situation." Focusing on blaming is a form of entitlement, and it is not healthy for a recovery from chronic pain.

The most important thing to remember about entitlement is that it is a natural response to extended pain and disability; but if it is not adequately addressed and resolved it can completely interfere with recovery.

Other Factors Influencing Pain and Suffering

In working with chronic pain patients, it is important to be aware of other factors that can influence pain, suffering, and disability. These primarily involve behavioral factors, as originally identified by Fordyce (1988).

Positive reinforcement of pain behavior

Pain behaviors are the actions that help us communicate to others around us that we are experiencing pain. These might include such behaviors as talking about the pain, taking pain medicine, yelling out, grimacing, groaning, moving slowly, and/or being very silent. It is only through these types of behaviors that others can try to gauge our level of pain experience. Pain is an individual experience that cannot be directly measured, so we use pain behaviors to communicate our distress.

Any behavior that we exhibit can be reinforced by those around us. Further, any behavior that is reinforced, by definition, will increase in frequency. For example, research studies have shown that if you get a classroom of students to pay attention to the teacher each time he moves to the left side of the classroom and to ignore him when he is on the right side, after a while he will be teaching the entire class from the left side of the room. Even more interesting is that the teacher will not be aware that this reinforcement of being on the left side of the classroom is even occurring. Other examples of behaviors that are reinforced throughout the day include working for a paycheck, recreational activities, and family interactions.

As with any behavior, pain behavior can also be reinforced by the environment around the patient; this most commonly occurs in the family setting. Thus, it is very important for the pain management clinician to get a good understanding of how the family system is responding to the patient’s display of pain behaviors. Reinforcement of pain behaviors can be very direct and obvious, such as:

These are examples of direct attention (reinforcement) for pain behaviors. Reinforcement can also be quite subtle, as can be seen in the following example given by Dr. Fordyce, the pioneer in this area of pain research:

The pain-ridden wife walks across the room without displaying pain and her paper-reading husband does not look up. When she limps, holds her back, or gasps while walking, his attention is diverted to her, and he watches and perhaps makes a solicitous comment.

In this next case, Dr. Fordyce also gives an extreme but not uncommon example of how powerful direct reinforcement can be:

The patient was a man in his forties who had been incapacitated for nearly twenty years. His wife worked to supplement his disability income. The husband was completely deactivated, spending most of his time in bed watching TV. She would prepare dinner for him in the evenings and bring it to the bedroom. When he would make an attempt to get out of bed to eat in another room or socialize with friends, his wife would chastise him for taking such risks. Her nurturing behavior was actually being reinforced by his decrease in pain behaviors each time she attended to him. In addition, his pain behaviors were continually reinforced by her attention to them. It is similar to parents who indulge a whining child. The indulgent behavior is reinforced by the temporary cessation of the child's whining while the whining is reinforced over the long term by continued attention from the parents.

Direct reinforcement of pain behaviors can increase both disability and suffering, which in turn increase one's perception of pain. It is important to note that direct reinforcement of pain behaviors (as with the other influences to be discussed next) are most likely to have influences in the chronic pain stages, after most tissue-healing has occurred. This is usually considered important four to six months after the onset of pain, consistent with Gatchel’s model of transitioning from acute to chronic pain.

Avoidance learning

Behavior can also be influenced by what has been termed avoidance learning. This is behavior that we engage in to keep away from consequences that are negative or aversive. In this way, those behaviors are actually being reinforced. Avoidance learning can also influence pain behaviors; behaviors will be reinforced in an attempt to avoid the pain. Dr. Fordyce gives the following examples:

A certain limp or posture is found to be effective in being more comfortable and in avoiding the pain. Thus, it is reinforced each time it is rehearsed, and becomes part of the person's usual behavior.

Bed rest is found to decrease the pain. Thus, in order to avoid any pain, the person spends more and more time in bed. Any time an increase in activity is attempted, the pain increases more and more due to weakening of muscles and other factors. Attempts at becoming more active are punished by increased pain, and bed rest is reinforced by avoidance learning.

A patient may know that walking more than three hundred yards has resulted in increased pain in the past. Therefore, whenever this goal is approached, the expectation for increased pain occurs. The patient will then avoid coming near the three hundred-yard mark in the walking program.

Early in the history of a pain problem, a limp is reinforced by avoiding pain. After some time, the limp itself leads to reinforcing from family members and others (e.g., "Let me help you," "I'll take care of that," and "Don't walk all that way; I'll drive you" ). At this point, it may not be necessary for pain to occur for the person to limp. It is an independent behavior in and of itself.

These examples illustrate in simple terms what is actually a complex and subtle process. Another area that has received great attention in research recently is avoidance learning as it relates to job dissatisfaction and lack of recovery from back pain. In the Boeing Study, researchers at the University of Washington found that one of the strongest predictors of whether a worker would have prolonged back injury disability was job dissatisfaction. One would think it might be something like heavy work, bending, problems with one's spine, or some other "physical" explanation. This was not the case.

It is important to underscore the fact that the person who is experiencing the pain, as well as his family members, is usually completely unaware of these influences of reinforcement and avoidance learning.

Reinforcement by the medical community

Dr. Fordyce also points out that the medical community can actually foster pain behavior and disability in the following ways:

The first of these factors is fairly straightforward. It simply entails the attention that one receives from the medical community when seeking treatment for a chronic pain problem. We have treated many chronic pain patients who clearly obtain a type of nurturance from their relationships with various aspects of the medical community. This might include such factors as seeing the physical therapist a few times per week for hot packs and massage, visiting the doctor on a frequent basis, or going into the hospital occasionally for management of a pain "flare-up." We will often see this pattern of reinforcement in patients who have very few other areas of reinforcement. An example of this might be the person who has lost his job due to pain, has few supportive family relationships, and no recreational interests. In this scenario (which we see often), the pain problem and its treatment is virtually the center of the person's life.

The use of pain medications can be a powerful reinforcer for pain behavior. This topic is more fully explored in Chapter 5, and will only be briefly mentioned here. Pain medications are often prescribed on a "pm" (as needed) basis. Under this prescription, pain medications are given when the person is experiencing pain (showing pain behaviors) and are not given when there are no pain behaviors. This method would appear to make common sense, but it can actually set up strong influences over pain behavior. Pain medication provides pain relief as well as an improved sense of emotional well being. This improved sense of well being might include such things as relief from anxiety, a general sense of relaxation, or improved energy and sleep in the person who is depressed. Given the fact that pain medicine can be very reinforcing, pain behaviors can quickly come under their influence. This occurs because the person must usually demonstrate pain behaviors in order to justify the request for pain medicines. The pain medicines are then taken, reinforcing the pain behaviors. As the pain becomes more chronic, the likelihood of pain behaviors being reinforced by pain medicine use becomes greater and greater. Physicians will often play a role in this process as apparent solutions to the pain problem become fewer and fewer. A common response by the chronic pain patient is, "Do something!" which unfortunately often results in the physician throwing more pain medications at the problem.

The medical community can also inadvertently reinforce chronic pain behaviors by how it manages bed rest and activity. For instance, in treating musculoskeletal and other chronic pain problems, the prescription for extended bed rest is common. This is often followed by the admonition to "let the pain be your guide" in terms of activity. In the majority of cases, the pain becomes more chronic and this type of approach will actually make the entire problem worse, not better. This medical advice simply reinforces the entire sick role in both the patient and those around her. It also creates much of the unnecessary disability we see with chronic pain sufferers.

Difficulty coping with being well

As Dr. M. Scott Peck has stated so eloquently and succinctly in his book, The Road Less Traveled, "Life is difficult." In some cases of chronic pain, the multidisciplinary assessment will reveal that part of the pain problem relates to the patient not being able to cope with being well. This is not a conscious decision on the part of the patient. Rather the stress of coping with being well is more negative than focusing on the chronic pain and being in the sick role. Thus, the chronic pain actually shelters the patient from stress, responsibility demands, and other aspects of normal everyday life. In these cases, it is important to assess the "cost" (in psychological, physical, and emotional terms) for the person to actually get better. The following example will help illustrate this point:

Mr. T. was a fifty-three-year-old railroad conductor who injured his back while attempting to throw a large railroad track switch. He had been through the usual course of physical therapy, but his back pain continued. He had an MRI that revealed a slight disc bulge, but the doctors did not think these findings accounted for his level of pain. He had been disabled from work for approximately twelve months at the time of our assessment. As with the previous doctors, the physical evaluation revealed little that would account for his pain. However, the psychological evaluation revealed several things that helped explain his pain. First, he had been experiencing more and more stress in the work setting just prior to the injury. He had a new boss who was constantly "on" him. The patient was very concerned about his ability to do the job given his age and the number of younger people who were ready to take his place. He feared his new boss was trying to "get rid” of him. In addition, the railroad disability program allowed him to collect 80 percent of his full pay while he was disabled. He might also be eligible for early medical retirement or retraining if the back pain did not resolve.

This example clearly indicates that the "cost" for this patient to get better was to return to a job that was becoming more and more stressful, return to a job from which he might be fired, lose the possibility of retraining, and give up 80 percent of his pay for being in a less stressful (albeit painful) situation. It should be clearly understood that this situation does not show malingering or faking. It is just a situation of many pressures operating on this person's chronic pain problem. The pain situation protected him from another situation that, for him, was even worse. Another less extreme example follows:

Sharon is a thirty-year-old woman who has been rather "sickly" since childhood. She had back pain that seemed to "come out of nowhere" and had been with her for the past two years. She had been through a variety of evaluations and treatment approaches, which were of little help. She would consistently report some relief at the beginning of treatment, but the pain would eventually return to its usual levels. Our evaluation revealed that Sharon had a very inconsistent work history, a number of failed relationships, and little in the way of social involvement. The last two years had been almost entirely focused on her back pain problem in terms of going to doctors, therapists, and other healers. It was clear that the back pain was helping to distract her from other very stressful aspects of her life and sheltering her from the demands of normal functioning. The cost for her to become well would have been very great without help in other areas of her life. Although she was very depressed and anxious in her chronic back pain problem, the other prospects were certainly no better. Until she was able to focus on these issues, her back pain would not resolve.

Conclusions

In thinking about a patient’s chronic pain problem, it is important to assess whether the pain is being influenced by any of the factors discussed above. To summarize, these include factors such as nociception, thoughts, emotions, pain sensation, suffering, pain behaviors, and the psychosocial environment. It is important to acknowledge the power that emotions can have on a patient’s chronic pain, including:

The longer the pain lingers, the more likely one or more of these emotions is increasing the pain. The influence of nonphysical factors on chronic pain, disability, and suffering must be acknowledged. Very few physicians will take all of these aspects into account, even though recent research indicates they may be among the most important in chronic pain cases. These factors include:

If any of these influences are part of the chronic pain problem, they need to be addressed or the problem will not be likely to resolve. Getting the patient to be aware and accepting of these factors is the first step in teaching effective pain management skills.

Chapter Three: Assessment of Chronic Pain

As discussed by Turk and Monarch (2002), chronic pain should be assessed from a biopsychosocial perspective. This is consistent with the gate control and pain system models discussed previously. The biopsychosocial perspective takes into account biologic, affective, cognitive, behavioral, and sociocultural influences on pain.

The clinical health psychology assessment model developed by Belar and Deardorff (1995, 2008) is useful in completing a biopsychosocial assessment of chronic pain. The following is adapted from Belar and Deardorff, Clinical Health Psychology in Medical Settings, Second Edition (APA Books, Washington D.C., 2008).

Targets of Assessment

In the biopsychosocial assessment of chronic pain, there are various “targets” of assessment that should be addressed. The target groups form a 4 X 4 assessment grid (domain of information by unit of assessment). The domains of information include biologic or physical, affective, cognitive, or behavioral. The units of assessment include patient, family, health care system, and sociocultural context. The following table shows some examples of the kinds of information that might be collected. For a more detailed example, see Belar & Deardorff (1995, 2008).

Environments
	Patient	Family	Healthcare System	Sociocultural
Biologic	age, race, sex, physical appearance, symptoms, health, vital signs, lab data, medications, genetics	home setting, economics, family size, family illness	treatment setting, medical procedures, prosthetics	social services, financial issues, social networks, occupational, health hazards
Affective	mood, affect, feelings about treatment and other aspects of chronic pain, history of affective disorder	family feelings about patient, illness, and treatment	providers’ feelings about patient, illness, and treatment	sentiment of the culture about patient, illness, and treatment
Cognitive	cognitive style, thought content, intelligence, education	knowledge about illness, attitudes and expectations	provider knowledge, provider attitudes	current state of knowledge, cultural attitude
Behavioral	activity level, interactions with others	involvement in care	provider skills, education, and training	employer, laws, customs

Each block also has an associated developmental or historical perspective that could be critical to a full understanding of the patient’s present condition. In each area, the clinician should attempt to understand the patient's (a) current status, (b) changes since onset of the pain, and (c) past history. The focus of the assessment should not be based solely on identification of problems but also on the delineation of assets, resources, and strengths of the patient and his environment.

Patient Targets

The patient targets of assessment include biological, affective, cognitive, and behavioral. In many ways, these targets of assessment coincide with the “layers” of the pain system model as presented previously (e.g., nociceptive input, pain sensation, cognitive, affective, pain behaviors, psychosocial environment)

Biological Targets

The most obvious biological targets are the patient's age, race, sex, and physical appearance. In addition, the clinician needs to gain a thorough understanding of the patient's current pain and other physiological symptoms, and how they are similar or dissimilar to past symptoms. Recent changes in the pain condition or treatment are particularly salient to the assessment because they are often the precipitating events that elicit the referral (e.g., increased pain, decreased function, contemplation of surgery). The clinician will want to obtain information on the specifics of the pain problem—nature, location, and frequency of symptoms; current treatment regimen; and general health status or other medical problems. Other sources of biological information include the physical exam, current and past vital signs, results from relevant laboratory tests, medications, and use of illicit drugs. Furthermore, a history of the patient's constitution and general health including previous illnesses, relevant genetic information, injuries, and surgeries should be obtained.

Depending on the type of pain problem, biological targets might also include variables associated with the autonomic nervous system or musculoskeletal activity (e.g., electromyographic (EMG) recordings or peripheral temperature readings) obtained in both resting and stress-related conditions. For example, a psychophysiological profile involving lumbar paraspinal EMG activity under relaxed and stressed conditions, in addition to various postures, could be obtained on a patient suffering from chronic low back pain.

As will be discussed subsequently, the use of a pain questionnaire and a pain activities diary can be very helpful in assessing biological and other targets.

Affective Targets

The assessment of affective targets involves understanding the patient's current mood and affect, including their contextual elements and historical features. In addition, an assessment would be incomplete without having obtained information about the patient's feelings about her pain problems, treatment, health care providers, future, social support network, and, of course, self. Again, it is helpful to obtain data that allow for comparison between current affective states and those of the past, in that it is often the contrast that has prompted the referral.

Cognitive Targets

Assessment of the patient's cognitive functioning involves gathering information about the patient's knowledge, perceptions, and attitudes, as well as the content and pattern of thinking. It is imperative that the clinician be aware of cognitive abilities and limitations of the patient, from both current and developmental perspectives. Cognitive targets include general intelligence; educational level; specific knowledge concerning the pain problem and treatment; attitudes toward health, illness, and health care providers; perceived threat of illness; perceived control over psychological and physical symptoms; perception of costs and benefits of possible treatment regimens; and expectations about future outcome. Another important target is the perceived meaning of the chronic pain problem (and resulting loss of function) to the patient. The clinician should be aware of the patient's general cognitive style and philosophy of life, including religious beliefs. Assessment of the patient’s religious and spiritual beliefs is an area of assessment and intervention that is very often neglected. Research indicates this is one of the most important areas to patients but the least often addressed by health care providers (see Deardorff and Reeves, 1997, for a review).

Behavioral Targets

Behavioral targets include what the patient is doing (the action) and the manner in which he does it (the style). In assessing pain behaviors, the following actions are often evaluated:

The style of behavior can also be evaluated such as flamboyant, hesitant, age-appropriate, hostile, restless, and passive. The pain management clinician will want to understand the patient's overall level, pattern, and style of activity in areas of self-care and interpersonal, occupational, and recreational functioning, as well as specific behavioral targets related to the reason for referral. Other important behavioral targets in chronic pain include medication seeking, exercise, activities of daily living (ADLs), sexual functioning, and compliance with treatment regimens.

Of special interest is the patterning and nature of the physician-patient relationship, as well as whether the patient senses any type of control over the pain problem. Once again, a historical perspective is important because past behavior is often the best predictor of future behavior.

Extremely significant in pain psychology is the assessment of current and previous health habits (e.g., smoking, exercise, eating patterns, and alcohol usage) and health care utilization. The clinician should be able to answer the following questions about the patient—(a) What are the nature, frequency, and pattern of past contacts with health service providers, and (b) what have been the antecedent stimuli and consequences of these contacts (i.e., history of previous help-seeking and treatments)?

Finally, an assessment would be incomplete without information concerning the patient's current and past history of compliance or adherence to treatment regimens, with specific reasons for noncompliance noted whenever it has occurred. Areas of assessment here include medication usage as prescribed, history of keeping appointments, and follow-through on previous recommendations.

Environmental Targets

The pain management clinician also needs to assess aspects of the various environments within which the chronic pain patient interacts. These include (a) the family unit, (b) the health care system with its various settings and providers, and (c) the sociocultural environment, including social network, occupational setting, and aspects related to ethnicity and cultural background. As with assessment of the individual patient, environmental targets of assessment include physical, affective, cognitive, and behavioral domains, with a focus on relevant demands, limitations, and supports.

Family environment. In assessing the physical domain of the family environment, it is important to know about available economic resources and perhaps even physical characteristics of the home setting, depending on the problem being assessed (e.g., chronic low back pain). The family's developmental history, size, and experience of recent changes are all important aspects to consider. The clinician should also be aware of other illnesses and pain problems in family members and familial models for various symptoms (e.g., a parent who has been disabled due to chronic pain).

In the affective domain, it is important to understand family members' feelings about the patient, the patient's pain problem, and the treatments rendered. Assessment of past or present affective disorders in the family is essential.

In the cognitive domain, the clinician must assess the family's attitudes, perceptions, and expectations about the patient, the patient's pain problem and treatment, and the future. Family members' intellectual resources, as well as knowledge that they possess about health and the pain problem, should be understood.

In the behavioral domain, the clinician will want to know whether there have been any changes within the family since the onset of the chronic pain problem. An example would be a shift in roles and responsibilities of family members due to the chronic pain patient’s lack of ability to function (e.g., at home and at work). It is also important to find out to what degree family members participate in the patient's care. As discussed under the pain system model, reinforcement contingencies can have a powerful effect on pain behavior. The clinician should investigate how the patient’s pain and illness behaviors are being reinforced by the family members to the exclusion of wellness behaviors. Pain behaviors might be positively reinforced (e.g., nurturing and “supportive” help for the patient) and negatively reinforced (e.g., removing the patient from stressful responsibility demands, family members taking over the household chores and ADLs). Consider the following example based on an actual case referred for psychological pain assessment:

Mr. Smith had been disabled from his job for one year after a low back work injury. The patient had undergone a variety of diagnostic tests; these had not identified likely pain generators. Although the patient complained of extreme pain, the physical findings simply did not explain his level of suffering and disability. Prior to his injury, he had been working two jobs -- neither of which he enjoyed – to support the family. After the injury, he was receiving disability payments, and his wife had returned to work to help support the family. Mr. Smith spent virtually all of his time at home, in bed. Mr. Smith was on a significant amount of pain medicine and his doctor was able to get the insurance company to buy Mr. Smith a hospital bed for his home. The family put the bed in the living room so that Mr. Smith could interact more with his children, who were very helpful in taking care of him. So far, a myriad of physical treatments had provided no relief.

As can be seen, assessment of behaviors of family members that could influence the patient's pain behavior or physical adaptation is crucial. For example, families might model chronic pain behavior, punish patient attempts at self-help, or be secretive in a manner that increases patient anxiety.

Health care system. The health care system should also be assessed across physical, affective, cognitive, and behavioral domains. For example, in the first domain the clinician needs to know the physical characteristics of the setting in which the patient is being assessed or treated (e.g., chronic pain program, surgeon’s practice, multiple doctors). In addition, the pain management clinician must understand the physical characteristics of the diagnostic procedures and the treatment regimen to which the patient has been, is being, or will be exposed. This is why it is important for the clinician to be familiar with the type of chronic pain problem that is being treated. As an example, anyone who works with spinal disorders and resulting pain problems should be familiar with the common diagnostic tests (e.g., MRI, CT, CT-myleogram, discogram, bone scan, EMG, NCS) and common medical treatments (e.g., physical therapy, medications, epidural and nerve root blocks, and the various spine surgeries).

In the affective domain, one must be aware of how health care providers feel about the patient and about the patient's chronic pain problem. In addition, the attitudes of providers themselves toward the health care system within which they work can enhance or detract from overall health care. Chronic pain patients who are on disability and not showing any significant response to various medical treatments can become frustrating to healthcare providers who are continuing with a strictly medical model approach (e.g., medications, surgery, physical modalities). After awhile, one might see a certain passive-aggressiveness by the healthcare providers towards the patient as frustration mounts. Of course, the symptoms of the chronic pain patient will often worsen due to attempts to “prove” the severity of her ongoing symptoms and need for treatment.

In the cognitive domain, the clinician needs to have some understanding of how knowledgeable health care providers are about the patient's pain problem and treatment. As discussed earlier, one often observes that all pain problems are treated as if they are “acute” in the medical community. Of course, this is not the appropriate intervention for chronic pain problems. One needs to assess healthcare providers’ attitudes and expectations about these issues as well as about the patient's future. Furthermore, it is helpful to be aware of the community standard of care for the problem. When assessing the "behavior" of the overall health care system, the clinician needs to be aware of policies, rules, and regulations that will affect the patient and her treatment (e.g., staffing patterns at the treatment center, appointment schedules, medication refill policies). It is also important to understand which specific behaviors health care providers might be displaying that could influence patient behavior. An example of this would be transmitting information about the pain problem. I have heard countless stories of chronic back pain patients being told by their physician, “you have the spine of an 80-year old.” Of course, this type of information significantly influences the patient’s belief system and expectation regarding future recovery (or lack thereof).

Sociocultural environment. Physical aspects of the patient's sociocultural environment include both (a) the physical requirements and flexibilities of the patient's occupational and work setting, and (b) the social and financial resources/services available to the patient. In addition, the clinician should be aware of the nature of the patient's social network (including size, density, and proximity) and the frequency of the patient's contact with it. This is an extremely important area of assessment in chronic pain. It is not uncommon for a chronic pain patient to be referred for psychological pain management near the end of the treatment cycle. By that time, the patient has often been on disability from work for quite some time, is in financial trouble, and is almost completely isolated from previous social support networks outside of the home. All of these factors act as significant barriers to recovery.

In the affective and cognitive domains, the clinician should understand cultural sentiments, attitudes, and expectations as impacted by the patient's race, gender, ethnicity, lifestyle, religion, pain problem, and treatment (e.g., sentiments about a chronic pain problem and disability in a person who was previously the primary breadwinner of the household). The clinician should be able to answer the following questions: What are the cultural attitudes towards the pain problem and disability? What is the health belief model of the culture itself? Are there prevalent religious beliefs that could impact the patient's willingness to obtain treatment?

In terms of the behavior of large sociocultural systems, the clinician might need to know specific employment policies related to the pain problem being assessed (e.g., regulations regarding return to work for patients with back problems). In addition, legislation regulating health care provision and health habits is relevant (e.g., The Americans with Disability Act, state Workers’ Compensation Laws) Finally, the clinician should be aware of ethnic customs that could be related to symptom reporting (or underreporting) and health care use.

Integrating Assessment Information

It becomes clear from a review of the targets for assessment that these "blocks" are interrelated, and that the nature or relative importance of information obtained in one block is often affected by information found in another. For example, type and location of the pain problem can affect perceived meanings of the physical symptoms because of the special psychological significance of certain body parts (face, back, pelvic, or extremity pain may carry different meanings for the patient).

Integrating assessment information is critical in the evaluation of a chronic pain patient. It is also important to gather accurate information across as many “blocks” of assessment data as possible. This is because a chronic pain patient is often being treated by more than one provider. It is not uncommon to have a patient who is being treated by a pain management physician, physical therapist, internist, pain management clinician, surgeon, and others. Patient self-report and questionnaires are only two data sources, and the information may or may not be entirely accurate. For instance, patients often do not know the medical diagnosis for their pain problem, do not remember or know the details of their medication regimen, or do not understand the surgeries they are facing (or have undergone). In addition, a patient may be reluctant to discuss a past history of medication abuse, but this information would likely be available elsewhere. Of course, the results of any psychological testing would be impacted by such things as medication use, level of concentration, substance abuse, and the ability to tolerate the pain and maintain focus while taking a lengthy test such as the MMPI-2. As can be seen, information gathered across assessment blocks should be compared and contrasted to determine consistencies and inconsistencies.

In conducting an assessment, it is important to understand that the data obtained could be influenced by the type of setting in which the assessment occurs. For example, low-back-pain patients often walk with greater or lesser flexibility depending on who is watching them and in what setting they are being observed. The pain management clinician should be collecting all observational data that is available (examples include the patient walking from the parking lot to the office, the patient sitting in the waiting room, the patient interacting with staff). Consider the following example:

A low-back-pain patient in an inpatient, chronic pain program was repeatedly observed ambulating with a walker by program personnel. However, on one occasion, when the patient was unaware that he was being observed, he was seen casually carrying his walker over his shoulder while ambulating with appropriate body posture and gait.

Patient expectations about the purpose of the assessment clearly influence the data obtained. For example, the demand characteristics for patients seeking a spine surgery that he believes will “cure” the pain will clearly impact how the pain evaluation is approached. When evaluating a chronic pain patient, it is imperative to take into account the reason for the evaluation. Various evaluation purposes include:

The patient who is undergoing a psychological pain evaluation in pursuit of treatment will likely respond very differently from the one that is being assessed for disability or litigation issues. The purpose of the evaluation should be clearly discussed with the patient at the beginning as part of the informed consent process.

The presence of other people, their roles, and their behaviors can also affect responses during assessment. For instance, one might witness the emotional breakdown of a chronic pain patient only a few moments after the patient assured his physician that he was doing “fine” or felt ready for some type of proposed treatment or surgery. Or, one might see the reluctance of patients to reveal even significant physical symptoms because of the perception of their physician as being too rushed. The pain management clinician working with chronic pain patients will often be able to obtain much more information than the treating physician will. This underscores the importance of communication amongst treating professionals.

The following are more examples of relationships that influence the interpretation of information obtained during assessment: