Awareness the role that early life events play in the human experience—namely, adverse childhood experiences (ACE)—is fundamental to understanding how patients relate to their internal world and outside environment. ACE include verbal abuse, physical abuse, sexual abuse by an adult/or someone 5 years older, neglect, witnessing domestic violence, parental divorce, substance use in home, mental illness of someone in the home, and/or history of prison sentence of someone in the home. ACEs have been associated with a myriad of adverse health and behavior outcomes, including the development of pain conditions.^5,6,7,8,9 The negative impact of ACE is believed to occur through increased pituitary adrenal and autonomic nervous system reactivity, as evidenced by increased reactivity when compared to counterparts who have not experienced significant adverse events.^10,11,12,13 The relational strength seen between ACEs and the development of negative health outcomes can be mediated by a combination of psychological and physiologic factors such as negative schemas, decreased mood, decreased positive health behaviors, suppressed immunologic function, and increased stress reactivity.^3,14,15,16 Given the role that early life experiences can play in the development of pain conditions over time, it is important to assess this aspect of patients’ personal history in the clinical interview. This process can be facilitated by use of the Adverse Childhood Experience Questionnaire, a free, 10-item measure in which a score of 4 and above that indicates a higher likelihood of negative health outcomes.⁵

Past and current vocational functioning provides perspective regarding patients’ activity patterns and is also predictive of the development of and prognosis for pain-related issues. A prospective study of 3,020 volunteers assessing risk factors associated with later back injury claims found that job dissatisfaction was the most predictive individual factor for reporting work-related low back pain over the course of time.¹⁷ Subsequent studies of job satisfaction have further reinforced its predictive value in pain-related disability. It has been postulated that work satisfaction may serve as a protective factor for adverse pain outcomes across different work environments and socioeconomic groups.¹⁸ The postinjury work environment itself also plays a role in pain outcomes. The lack of work place modifications to accommodate the limitations caused by the injury and the inability to modify the pace at which one completes job-related tasks are both predictive of chronic pain-related disability.¹⁹

All of the aforementioned underscores potential secondary gain variables that may influence response to treatment and should thus be explored in greater detail. It is imperative to note that these variables are not limited to the vocational environment: factors that can reinforce maintenance of impaired functioning should be assessed across all domains of patients’ lives. If such influences are detected, it is useful for clinicians to delineate the mechanism by which they may be shaping response to treatment rather than merely identifying a clinical situation as having potential for secondary gain, as the latter can have negative ramifications for patients.²⁰ Finally, although it is important to assess for its presence, it is also incumbent on the clinician to ensure that a lack of response to treatment is not inappropriately attributed to secondary gain.

Educational history is another patient variable that is known to influence chronic pain. A study examining correlates of back pain in German patients found that level of education significantly predicted low back pain and accounted for a large majority of the variance in the differences across age and gender.²¹ Large-scale studies in other countries have also found links between education and pain. In a study of 17,543 adults from Australia, lower levels of completed education, unemployment benefits, and being unemployed for health reasons were all associated with having chronic pain.²² A study of 8,970 individuals from Finland found an “educational gradient” for both chronic and disabling chronic pain, where lower levels of education were associated with a higher prevalence of chronic pain and disability.²³ Low educational attainment is strongly associated with low back pain, and this is believed to function primarily through psychological factors and health behaviors such as smoking, diet, exercise, and obesity.²⁴ An analysis targeting the link between education and pain found that individuals with lower levels of education achievement were more likely to report pain as a signal of harm and had increased self-reported disability, potentially explaining the mediating psychological factors between level of education and pain.²⁵ There is also
evidence that the course of back pain is less successful for individuals with lower levels of education.²⁶ Level of education is of particular importance in understanding psychological and health literacy barriers that can impact pain treatment. Information related to education can be obtained by assessing level of academic preparation (e.g., less than high school, high school, college, and graduate school).

Individuals’ belief structures about their pain can influence their overall adjustment to the condition itself.²⁸ Pain catastrophization is characterized by maladaptive, exaggerated thoughts, and emotions about actual or anticipated pain. It is strongly associated with poor treatment outcomes across the life span and is predictive of function, opioid use, and pain intensity.^34,35 Individuals who engage in high levels of pain catastrophization are often somatically hypervigilant at baseline which can lead to both increased pain perception and affective distress. Activity reduction is frequently employed as a coping strategy to escape pain, but this approach can result in the development of a fear avoidance cycle. The latter construct refers to avoidance of activity secondary to fear of reinjury, pain, or worsening of the underlying condition. Over the course of time, the avoidance of activity contributes to emotional distress and declining physical functioning which further reinforces the fear. Fear avoidance beliefs are self-perpetuating in nature and are predictive of functional limitations and perceived disability.³⁶

In addition to data gleaned from the clinical interview, there are a number of devices available to assist with the assessment of catastrophic and fear avoidance beliefs. The Pain Catastrophizing Scale (PCS)³⁷ is a commonly used device composed of 13 items rated on a Likert scale. In addition to general tendencies toward catastrophization, subscales indicate the extent to which the respondent’s cognitions are characterized by magnification, rumination, and helplessness. The Fear-Avoidance Beliefs Questionnaire (FABQ)³⁸ and the Pain Anxiety Symptoms Scale (PASS-20)³⁹ assess various aspects of the fear-avoidance cycle. The FABQ was specifically developed to assess patients’ beliefs as they relate to low back pain. It is composed of 16 items scored on a 7-point Likert scale and yields scores on two subscales: Scale 1 assesses fear-avoidance beliefs about work and Scale 2 assesses fear-avoidance beliefs about general physical activity. The PASS-20 is composed of 20 items on a 6-point Likert scale. It measures pain-related anxiety across four subscales: cognitive, escape/avoidance, fear, and physiologic anxiety.

Beyond interpretation of pain, it is also useful to assess patients’ beliefs regarding the role that they play in their own care. There are differences in how treatment is approached in acute versus chronic pain: Patients often assume a more passive role in the former, whereas the latter requires active self-management. Assessing patients’ understanding of this process and providing appropriate education can facilitate their ability to become active participants in their treatment plan.⁴⁰

Assessment for alignment in treatment expectations is also important. Clinicians and patients may have different perspectives regarding what constitutes a successful outcome: A clinician may perceive improvement in physical functioning despite the presence of pain as fitting in this category, whereas a patient may view this as unsuccessful due to the ongoing nature of the pain symptoms. The potential for such a discrepancy highlights the importance of ensuring that patients understand the treatments in which they will participate and that they have realistic expectations of outcomes they may experience.⁴¹

Social support factors relate to chronic pain conditions in a bidirectional fashion. Experiencing pain and resulting disability can further stress one’s family system and may create conflict, particularly if one is no longer able to complete their expected family responsibilities.^42,43,44 Supportive family systems can also reinforce disability as they may engage in overly solicitous behavior, which can lead to further disability and passivity in the patient.^45,46,47 This is evidenced through operant models of conditioning, where increased reinforcement of pain-related behavior translated to increased pain intensity and disability.⁴⁸ There is evidence to support further pain and disability with communal catastrophizing as well, where increased expression of distress can lead to exhaustion of social support.⁴⁹ At the same time, a dysfunctional family can further exacerbate patients’ conditions. Studies show that individuals who felt invalidated by a partner experienced more marital conflict, which in itself is associated with increased negative pain outcomes.⁵⁰ A longitudinal study assessing the impact of social support on pain outcomes found that immediately after a motor vehicle accident, social support did not relate to perceived pain ratings; however, at 6-week follow-up, individuals with less perceived social support had higher pain ratings than those with elevated social support, and this relationship was more significant for men than women and for those with depression.⁵¹ Assessing the level of social support is particularly relevant in chronic pain management, and evidence supports the need for assessment in acute instances as well. Depleted levels of support can predict negative outcomes; yet, overly solicitous social support can also be as deleterious. Evaluation in this arena should include information about the quantity, quality, and stability of the full range of past and present interpersonal connections, including marital, family, work, and other social relationships. The Social Provisions Scale is a free, 24-item, self-report questionnaire that has been validated across several samples that can provide useful data that complements information obtained from the clinical interview.⁵²

In its seminal report Relieving Pain in America, Institute of Medicine² specifically highlighted the importance of addressing cultural factors in the delivery of pain care. The literature has demonstrated variability across gender, ethnicity, race, and age influences the pain experience and patients’ responses to treatment.^53,54,55 Clinical interview questions should therefore focus on gathering information on the sociocultural background of patients, their families, and communities, including assessment for disparities that may affect access to care.