Psychological assessment of persons with chronic pain


Chapter 11
Psychological assessment of persons with chronic pain


Robert N. Jamison1 & Kenneth D. Craig2


1 Departments of Anesthesia and Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Chestnut Hill, Massachusetts, USA


2 Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada


Introduction


Psychological and social risk factors associated with greater pain severity and longevity, as well as poorer outcomes from treatment of pain, include pain chronicity, psychological distress, a history of abuse or trauma, poor social support and significant cognitive dysfunction and deficits [1, 2]. In particular, psychopathology and/or extreme emotionality have been recognized as contraindications for certain therapies [3]. Outcome studies highlight poor response to treatment among patients with psychiatric comorbidity, with this prevalent among persons with chronic pain, including comorbid opioid use disorder [4]. For example, spinal pain patients with both anxiety and depression have a 62% worse return‐to‐work rate than those with no psychopathology. Similarly, cognitive processes such as maladaptive beliefs and pessimistic expectations are associated with poorer functional outcomes among patients with chronic low back pain [5, 6]. Psychosocial issues typically become more important the longer pain remains a problem in the patient’s life. Early psychological assessment typically provides a statement of treatment objectives that could include psychological and social issues and allows ongoing assessment to help establish treatment effectiveness.


Psychological assessment is designed to identify problematic emotional reactions, maladaptive thinking and behavior and social problems that contribute to pain and disability. Routine assessment would seem imperative [7]. When psychosocial issues are identified, treatment can be tailored to addressing these challenges in the patient’s life, thereby improving the likelihood and speed of recovery and the prevention of ongoing or more severe problems [8, 9].


Components of a psychological assessment


A number of themes should be addressed during a thorough psychological assessment of a person with pain. Semi‐structured clinical interviews (Table 11.1) and self‐report instruments (Table 11.2) allow for assessment of the different domains of the pain experience, functional impairment and pain‐related disability. While these are the most common strategies, reports from others (e.g. family members or caregivers) and evidence of performance in life situations also are of value. Selection of the strategy requires consideration of whether the measure possesses good psychometric properties [10]. The following highlights those themes that should be assessed, with detailed assessment strategies following this account:



  1. Somatosensory qualities of the experience, with this usually best understood through description of the severity, location and temporal characteristics of painful experiences. Individuals who use many pain descriptors and are highly pain‐sensitive are at greater risk for poor long‐term pain outcomes.

    Table 11.1 Categories to be addressed during an interview.





























    1. Pain description and history of pain onset


    1. Aggravating and minimizing factors


    1. Past and current treatments, including medication use


    1. Daily activities: content and level


    1. Relevant medical history


    1. Development, education, family and employment history


    1. Compensation status, engagement in litigation


    1. Family and personal history of drug or alcohol abuse and substance dependence


    1. Family and personal history of psychiatric disturbance and treatment


    1. History of suicidal ideation and current emotional status


    1. Financial and social support


    1. Perceived directions for treatment

    Table 11.2 Selected assessment categories and frequently used psychometric measures.






















    Assessment Category Psychometric measures


    1. Psychosocial history
    		 Comprehensive pain questionnaire and demographic factors
    Structured clinical interview


    1. Pain intensity
    		 Numerical rating scales (NRS)
    Visual analog scales (VAS)
    Verbal rating scales (VRS)
    Pain drawings (PD)


    1. Mood and personality
    		 Patient‐Reported Outcomes Information System (PROMIS) Depression
    Patient Health Questionnaire (PHQ‐9)
    Hospital Anxiety and Depression Scale (HADS)
    Beck Depression Inventory (BDI‐II)
    Minnesota Multiphasic Personality Inventory (MMPI)*
    Symptom Checklist 90 (SCL‐90)
    Millon Behavior Health Inventory (MBHI)
    Center for Epidemiologic Studies Depression Scale (CES‐D)


    1. Functional capacity and quality of life
    		 Short‐Form Health Survey (SF‐36);
    Short Form 12 (SF12)
    Multidimensional Pain Inventory (WHYMPI)
    Pain Disability Index (PDI)


    1. Pain beliefs and coping
    		 Coping Strategies Questionnaire (CSQ)
    Pain Catastrophizing Scale (PCS)
    Survey of Pain Attitudes (SOPA)

    * See text for potential disadvantages in interpreting results in patients with chronic pain.


  2. Affective qualities of the experience. Distressing emotional qualities of a painful experience as well as pre‐existing emotional dispositions such as a mood disorder with associated anxiety, fear and depression contribute to heightened response to pain.
  3. Cognitive features, with patterns of thinking able to exacerbate and maintain dysfunctional pain, or, on the contrary, able to facilitate coping. Catastrophizing is a set of cognitive and emotional processes encompassing magnification of pain‐related stimuli, feelings of helplessness and a generally pessimistic orientation to pain outcomes. Higher catastrophizing predicts greater pain‐related disability and healthcare utilization. In contrast, perceived self‐efficacy, or confidence that one can deal with pain, is associated with better function and well‐being
  4. Pain behavior. There is substantial variability in the extent to which chronic pain interferes with activities of daily living or contributes to functional impairment. A careful appraisal of pain behavior through observation of patients both during and outside the examining situation can be of value, for example, when engaged in spontaneous activity in everyday situations.
  5. Personal history. Ethnic and cultural background, family socialization, and important life experiences influence the capacity to cope with pain. A history of trauma or physical or sexual abuse can have an adverse effect on coping with pain. When significant others in a person’s family have had a history of chronic or particularly severe pain, there may be a predisposition to similar patterns in the patient.
  6. Psychosocial stressors tend to negatively impact coping and result in increased healthcare utilization. Of particular importance would be current social contexts provoking distress (e.g. with employers or family members) either directly (e.g. unemployment, social isolation) or indirectly (e.g. dysfunctional relationships) related to painful episodes.
  7. Social context of the assessment can be very important. While clinicians must be aware of the objectives of referral sources, patients similarly are typically aware of the expectations and goals of referral agencies and those engaged in the assessment. Although the focus may be upon reducing painful distress, improving functional capacity, and reducing pain‐related disability, referral sources may be interested in credibility and legitimacy of pain complaints. Patients frustrated with lack of success from treatment and hampered by financial concerns and negative experiences may react differently in assessment situations than those without such experiences or concerns.

Clinical Interviews


Informal and semi‐structured interviews are core features of most clinical assessment. In addition to establishing patient/clinician relationships they ensure consistent coverage of critical information categories across patients. Table 11.1 describes basic information categories typically pursued during the initial interview.


Assessment Self‐Report Measures


To standardize outcome reporting among patients with chronic pain, an international multidisciplinary panel recommended pain intensity, physical functioning, and health‐related quality of life (HRQoL) as core outcome domains [11]. The Patient‐Reported Outcomes Measurement Information System (PROMIS) is a highly reliable, valid, publicly available assessment tool that measures these core domains. PROMIS has been used to successfully measure pain, fatigue, depression, anxiety, sleep disturbance, physical social and sexual function, and global quality of life among chronic pain patients and is frequently used in clinical outcome studies [12–15]. Other selected assessment categories and frequently used reliable and valid psychometric measures to assess the domains mentioned above are listed in Table 11.2.


Pain intensity


A number of tools have been devised to provide a global measure of how much the person hurts, including numerical pain ratings (NRS), visual analog scales (VAS), verbal rating scales (VRS), and faces scales (i.e., depictions of graded facial displays of distress) [16], using self‐monitored reliable and valid pain intensity ratings [17]. Among these self‐report measures, the NRS (e.g. 0–10 or 0–100 scale), tend to be most popular among professionals because they are easy to administer and score. However, there is no evidence to suggest that VAS or VRS are any less sensitive to treatment effects. Another popular means of measuring pain intensity is the VAS, which asks the patient to mark the point on the line that best indicates present pain severity between extreme limits of pain at either end [17]. Electronic VAS diaries have been shown to be as reliable as paper measures [18]. There are a number of VRS that consist of phrases (as few as 4 or as many as 15, often ranked in order of severity from “no pain” through “mild pain”, “moderate pain”, and “severe pain” to “excruciating pain”) chosen by the patients to describe the intensity of their pain [17]. They can be favored as they provide some qualitative information about subjective magnitude, in contrast to intensity ratings using the VAS or NRS. In addition, external validity is improved by descriptive anchors that establish the meaning of numerical values. Repeated assessment over time has a number of benefits: averaging multiple measures of pain intensity increases the reliability and validity of the assessment, reports serve as a baseline to establish whether continued treatment is needed after an appropriate trial period, and they allow assessing the overall impact of treatment for pain.Given concerns that single estimates of pain severity confound sensory, emotional, and cognitive features of the experience, the McGill Pain Questionnaire has been used to differentiate different sensory/discriminative, affective/motivational, and cognitive/appraisal qualities [19, 20]. Patients select from multiple verbal descriptors to characterize their pain on these dimensions. The current focus has been upon short forms useful in extracting a subscale of affective distress [21].


A popular assessment tool to measure the intensity and character of pain is the Brief Pain Inventory [22]. The BPI provides information about pain history, intensity, and location as well as the degree to which the pain interferes with daily activities, mood, and enjoyment of life. Scales (rated from 0 to 10) indicate the intensity of pain in general, at its worst, at its least, average pain, and pain “right now” over the past 24 hours. A figure representing the body is provided for the patient to shade the area corresponding to the location of his or her pain. Test‐retest reliability for the BPI reveals correlations of 93 for worst pain, 78 for usual pain, and 59 for pain now. Numerous studies have supported the reliability and validity of the BPI for the assessment of pain among patients with chronic pain conditions. The initial validation study yielded internal consistency (Cronbach’s alpha) coefficients of 85 and 88 for the intensity and interference subscales, respectively [23].


Mood and personality


Although depression, anxiety, and irritability can be a normal response to pain, individuals with chronic pain can frequently present with significant psychopathology and catastrophize about their pain, which can greatly interfere with coping and response to treatments for pain [24–26]. Up to 40% of chronic pain patients in primary care practices present with significant psychopathology. This percentage can increase to 75% in specialty pain practices [27]. Often these are individuals with a history of physical or sexual abuse, substance abuse or personality disorder. Patients with higher levels of negative affect present with more somatic complaints, have more pain, and are prone to greater utilization of medical services [28, 29].


Psychopathology and/or extreme emotionality have been seen as contraindications for certain therapies [8]. Mental health professionals continue to debate the best way to measure psychopathology and/or emotional distress in patients with chronic pain. Although most measures are helpful in ruling out severe psychiatric disturbance, unfortunately no measure can boast validity in predicting treatment outcome. A recent trend shows the PROMIS Depression [30, 31], the Patient Health Questionnaire‐9 (PHQ‐9) [30], the Beck Depression Inventory (BDI‐II) [33] and the Hospital Anxiety and Depression Scale (HADS) [34] to be frequently included in psychological assessments of persons with chronic pain [35]. A brief description of PROMIS scales has been provided above.


The PHQ‐9 is a brief, 9‐item, self‐report measure of depression. The BDI assesses depressive symptoms in patients with chronic pain. This 21‐item self‐report questionnaire measures the severity of depression and is commonly used to evaluate the outcome of treatment. It is easy to administer and score, although one limitation is the potential for misinterpretation of an elevated depression score as a result of the frequent endorsement of somatic items (e.g. fatigue, sleep disturbances and loss of sexual interest) by patients with chronic pain. The Center for Epidemiologic Studies Depression Scale (CES‐D) is an additional tool for assessment of depressive symptoms in patients with pain [34]. The HADS is a 14‐item scale designed to assess the presence and severity of anxious and depressive symptoms in people with medical illness—it excludes items of fatigue and sleeplessness which might be attributed to the physical disease. Seven items assess anxiety and seven items measure depression, each coded 0–3. The HADS has been used extensively in clinics and has adequate reliability and validity [34].


Measures that have been frequently used in the past to evaluate personality and emotional distress, but are less frequently used today, include the Minnesota Multiphasic Personality Inventory (MMPI‐2) [37], the Symptom Checklist 90 (SCL‐90‐R) [38], and the Millon Behavior Health Inventory (MBHI) [39]. The MMPI is an instrument traditionally used in assessing psychopathology. This 567 true– false item measure yields a distinct profile for each patient that can predict return‐to‐work in males following surgical treatment. Although this test has been widely used to measure psychopathology, the profiles obtained in people living with pain can be misinterpreted because of the physical symptoms reported by these patients [38]. Patients may also dislike the test’s emphasis on psychopathology.


The SCL‐90 is a 90‐item checklist general assessment of emotional distress that provides a global index of functioning score as well as nine subscale scores. It is a relatively brief measure including individual items that may pertain specifically to persons with chronic pain. Its disadvantages include a high correlation between subscales and the absence of validity scales to detect subtle inconsistencies in responses. The MBHI, another popular measure for assessing mood and personality among patients with pain, includes 150 true–false items and offers 20 subscales that measure: (a) styles of relating to providers; (b) psychosocial stressors; and (c) response to illness. Unlike other measures, the MBHI emphasizes medical rather than emotional concerns.


Functional Capacity


Some clinicians consider pain reduction meaningless unless accompanied by a noticeable change in function. Thus, some reliable measurement of level of activity should be used before and after the onset of therapy. Research has shown that physical impairment, defined as an objective medical condition, such as an amputation, is not very predictive of disability, which is an inability to work because of a medical impairment. Rather, beliefs about an injury predict disability and physical performance after surgery better than `pain ratings or a physical impairment’ [41, 42]. Measures that can be used to assess activity level and function include the Short‐Form Health Survey (SF‐36) [43], the West Haven‐Yale Multidimensional Pain Inventory (WHYMPI, mostly known now as the MPI) [44] and the Pain Disability Index (PDI) [45]. It is preferable to consider functional measures that are specific to the chronic pain condition being assessed (e.g., back pain patients will have different activity limitations than someone with upper extremity pain).


The SF‐36, which was initially developed from the Medical Outcomes Study to survey health status, includes eight scales that measure (1) limitations in physical activities due to health problems, (2) limitations in social activities due to physical and emotional problems, (3) limitations in usual role activities due to physical health problems, (4) bodily pain, (5) general mental health, (6) limitations in usual role activities due to emotional problems, (7) vitality (energy and fatigue), and (8) general health perceptions. Although the SF‐36 is a popular measure, pain patients tend to score very low (severe limitations) such that modest improvements can go undetected. An expanded measure known as the Treatment Outcomes of Pain System (TOPS) [46] that incorporates the SF‐36, has been modified specifically for patients with pain to improve sensitivity and reliability of measurement of treatment outcome.


The MPI is a 56‐item measure made up of 7‐point rating scales. The subscales assess activity interference, perceived support, pain severity, negative mood, and perceived control. The advantage of this self‐report instrument is that it was created specifically for chronic pain patients and can be useful in classifying those patients into three types: dysfunctional, interpersonally distressed, and adaptive copers [47]. Strong evidence supports the presence of these three types in the assessment of chronic pain patients [48].


Other popular functional measures include the Oswestry Disability Questionnaire [49], The Roland‐Morris Functional Disability Scale [49], the Waddell Disability Instrument [50], the Functional Rating Scale [51], and the Back Pain Function Scale [52].Kinesiophobia is the fear of pain due to movement, a potentially important factor contributing to disability among persons with chronic pain [53]. Studies have shown a connection between kinesiophobia and increased reported pain intensity and prolonged rehabilitation [53]. Thus, an assessment of kinesiophobia can be important [54]. The Tampa Scale of Kinesiophobia is a valid and reliable measure of this construct and is linked to catastrophic thinking [55, 56]. A shortened version of this measure is also available [57].


There has been a rapid increase in the use of motion sensors such as accelerometers, pedometers, heart‐rate monitors and multiple‐sensor devices to assess daily steps, position, and level of sleep [58]. Wearable technology that utilizes actigraphy is increasingly being used for the objective measurement of physical activity and sleep in various therapy areas, including among pain patients, as it is unintrusive and suitable for continuous tracking to allow longitudinal assessment [59]. Objective measures of movement (e.g., steps per day) have the potential of being more accurate than self‐reported levels of activity since self‐reports of activity level can be inaccurate and prone to recall bias. There is some preliminary evidence that activity monitors encourage increased function and correlate with improvements in mood among patients with chronic pain [60].


Pain beliefs and coping


Pain perception, beliefs about pain, and approaches to self‐managing pain are important in predicting the outcome of treatment. Unrealistic or negative thoughts about an ongoing pain problem may contribute to increased pain and emotional distress, decreased functioning, a greater reliance on medication and poor outcome from surgery [61]. Certain chronic pain patients are prone to maladaptive beliefs about their condition that may not be compatible with the physical nature of their pain [62]. Patients with adequate psychological functioning exhibit a greater tendency to ignore their pain, use coping self‐statements, remain active and use less medication for management of their pain [63]. Coping strategies may be defined as specific thoughts and behaviors individuals use to manage their pain or their emotional reactions to pain [64]. For example, “active” pain coping generally includes engaging in positive thinking, making encouraging self‐statements, distracting one’s attention from pain, undertaking as much physical activity as possible within pacing guidelines or using physical pain‐reducing techniques such as relaxation exercises and stretching. Facilitating such coping strategies seems to be an important part of many non‐pharmacologic treatments for chronic pain. One recent prospective study of multidisciplinary treatment revealed that patients who entered treatment with stronger personal beliefs in their ability to control pain, and those who increased their use of positive self‐statements and cognitive reinterpretation of pain, showed the most substantial decreases in pain‐related interference at 6 months and 18 months post‐treatment [65]. Coping strategies may affect the patient’s level of attentiveness to pain, the ability to persist in the face of pain, and the extent to which the patient feels entitled to be taken care of as a result of the pain.


Since efficacy expectations have been shown to influence the efforts patients will make to manage their pain, measures of self‐efficacy or perceived control are useful in assessing a patient’s attitude towards pain treatment [66]. Several self‐report measures assess coping and pain attitudes. The frequently used tests to measure maladaptive beliefs include the Coping Strategies Questionnaire (CSQ) [67], the Pain Management Inventory (PMI) [68], the Pain Self‐Efficacy Questionnaire (PSEQ) [69], the Survey of Pain Attitudes (SOPA) [70], and the Inventory of Negative Thoughts in Response to Pain (INTRP) [71]. Other instruments include the Pain Beliefs and Perceptions Inventory (PBPI) [72], and the Chronic Pain Self‐Efficacy Scale (CPSS) [73].


Psychological models of chronic pain, such as the fear‐avoidance model, demonstrate that the way people cognitively process their pain sensations is a strong determinant of their future pain‐related behavior [74]. Catastrophizing is a central variable in the fear‐avoidance model that accounts for 7–31% of the variance in pain severity [75]. In addition, pain catastrophizing creates maladaptive pain cognitions that can be a risk factor for developing depression, disability, and higher pain intensity [76, 77]. As a result, a great deal of empirical research has focused on the important concept of catastrophizing when assessing painful experiences [78–80]. While catastrophizing positively correlates with negative affect, including depression and anxiety, it also has a unique and specific influence on pain‐related outcomes [81]

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