Abstract
This chapter outlines the main components of psychological evaluations for persons with chronic pain, which are recommended to be included as part of a comprehensive pain management plan. The psychological evaluation typically includes a combination of a clinical interview as well as the use of standardized self-report scales and questionnaires to evaluate psychological, behavioral, and social factors. Key domains for assessment are described and include pain-related disability and behavior, emotional distress, such as depression and anxiety, psychopathology, pain-related cognitions and beliefs, coping strategies, and sleep disturbance. The most valid and commonly used scales and questionnaires for each domain are presented and discussed. A special focus is given to the implementation of psychological evaluations for suicide risk assessment, screening for substance use and opioid misuse, evaluation of the presence of symptoms exaggeration or malingering, and evaluations before interventional pain procedures, such as spinal cord stimulation. The comprehensive psychological evaluation can contribute to the understanding of factors that may precede and perpetuate patients’ pain as well as assist in designing appropriate interventions and long-term treatment plans, which can improve patient adherence and treatment outcome.
Keywords
anxiety, depression, pain coping, physical function, psychological testing, screening tools
Chronic pain is a multifaceted, subjective experience that is best understood as a complex interaction of physiological, psychological, and environmental variables. Extensive research has documented the role cognitive, emotional, and social factors play in the etiology and maintenance of chronic pain. Thus comprehensive assessment of chronic pain typically includes a psychological evaluation that can significantly improve the overall understanding of the patient and contribute to improved treatment outcomes. This chapter provides an overview of the key components of a psychological evaluation for chronic pain—the clinical interview, including behavioral observation, and the use of standardized assessment instruments.
Clinical Interview
While structured clinical interviews are available, most practitioners elect to conduct semistructured interviews that address multiple aspects of the individual’s cognitive, medical, educational, social, employment, and psychiatric history. The interview will include an assessment of mental status to determine if the individual is sufficiently cognitively intact to participate in the assessment and future treatments. Should concerns regarding cognitive impairments emerge, closer examination of cognitive functioning or a referral for a full neuropsychological evaluation is appropriate. If available, the practitioner may draw on collateral sources of information, such as significant others or family members. As part of the clinical interview, the psychologist will gather extensive information regarding the individual’s pain history and experience.
The clinical interview is the cornerstone of the psychological evaluation due to the subjective nature of the pain experience and the relatively limited set of standardized psychological measures that have normative data for chronic pain patients. Some individuals with chronic pain may be reluctant to participate in a psychological evaluation, due to the stigma associated with psychiatric illness or the concern that the provider may be suggesting that the pain is psychologically based. Referring physicians and other providers can reduce these concerns by informing patients that psychological evaluation is a routine component of comprehensive pain management. The practitioner conducting the psychological evaluation can establish credibility by beginning the interview with a focus on the patient’s pain experience and its impact on daily life and function. Once rapport is established, it is easier to progress to cognitive, social, and psychological aspects of the pain experience, including cognitive-affective variables involved in chronic pain. Symptoms of depression and anxiety are common among patients with chronic pain, and closely correlated are cognitions that render the person more vulnerable to increased pain and suffering. An important objective of the interview is to identify any psychiatric conditions that might exacerbate pain or complicate treatment, such as psychosis, substance dependence, or a personality disorder. Additionally, it is valuable to assess the patient’s sleeping patterns, specifically inquiring about any difficulties initiating or maintaining sleep as well as the presence of substantial fatigue or sleepiness impairing daily functioning. Finally, observation of pain behaviors can provide important information about the person’s overall pain experience, coping, and the extent of pain-related disability. Pain behaviors—such as ability to sit through the interview, verbal complaints, and other sounds (e.g., grunting and moaning), facial expressions (e.g., grimacing, wincing), and bodily gestures (e.g., bracing when changing positions, moving in a distorted fashion)—are noted during the interview.
Standardized Testing
One of the important elements a psychologist contributes in the overall assessment of a pain patient is expertise in the use of standardized testing instruments, which can provide data on the individual’s functioning relative to normative samples. Key assessment domains are presented here, along with instruments commonly used (the assessment of pain is included in other chapters of this volume). Important assessment domains include pain-related disability and behavior, psychological function and sleep, and pain-related beliefs, cognitions, and behaviors.
Multidimensional Instruments
When clinicians do not have the need, or opportunity, to administer a battery of assessment instruments, multidimensional measures might be used in the evaluation of pain and its emotional and behavioral correlates. One of the most widely used and studied of these instruments is the Multidimensional Pain Inventory (MPI; 56 items; Box 6.1 ). This multidimensional scale assesses psychosocial, cognitive, and behavioral aspects of pain, including pain severity and interference; activity levels, including household chores and work; impact of pain on family relationships and social activities; pain-specific support from spouse or partner; perceived life control; and negative affect. This measure is valuable in its ability to assess multiple dimensions of pain, its relative brevity, and its demonstrated responsivity to treatment effects. In addition, the MPI provides overall classification of the individual’s function as being “dysfunctional,” “interpersonally distressed,” or “adaptive coper.” However, research on the validity, utility, and distinctiveness of these classifications has yielded mixed results.
| Behavioral Aspect of Pain | Measurement Tool |
|---|---|
| Multidimensional | Multidimensional Pain Inventory |
| Disability and behavior | Brief Pain Inventory |
| Pain Disability Index | |
| Roland-Morris Disability Questionnaire | |
| Chronic Disability Index | |
| Oswestry Low Back Disability Questionnaire | |
| Sleep | Pittsburgh Sleep Quality Index |
| Insomnia Severity Index | |
| Depression | Center for Epidemiological Studies Depression Scale |
| Patient Health Questionnaire Depression Module | |
| Anxiety | Generalized Anxiety Disorder Scale |
| Hospital Anxiety and Depression Scale | |
| Pain Anxiety Symptoms Scale | |
| Psychopathology | Symptom Checklist-90-Revised |
| Minnesota Multiphasic Personality Inventory | |
| Coping | Coping Strategies Questionnaire |
| Chronic Pain Coping Inventory | |
| Beliefs, attitudes, and expectations | Survey of Pain Attitudes-Revised |
| Pain Beliefs and Perceptions Inventory | |
| Catastrophizing | Pain Catastrophizing Scale |
| Coping Strategies Questionnaire (catastrophizing subscale) | |
| Kinesiophobia | Tampa Scale of Kinesiophobia |
| Fear-Avoidance Beliefs Questionnaire | |
| Self-efficacy | Pain Self-Efficacy Questionnaire |
| Chronic Pain Self-Efficacy Scale | |
| Arthritis Self-Efficacy Scale | |
| Locus of control | Pain Locus of Control |
| Acceptance | Chronic Pain Acceptance Questionnaire |
Pain-Related Disability and Behavior
A number of validated questionnaires are available to assess a person’s perceived disability. The Brief Pain Inventory (BPI; 11 items) was developed to measure pain severity and pain-related interference in patients diagnosed with cancer. Later research extended its use to noncancer pain assessment, including heterogeneous pain conditions, osteoarthritis, and neuropathic pain. The most widely used version of this scale uses an 11-point numeric rating scale (where 0 = no interference and 10 = interferes completely) to assess pain-related interference in seven areas: general activity, mood, walking ability, normal work including outside the home and housework, relations with other people, enjoyment of life, and sleep. The BPI has been used to demonstrate the efficacy of pain medication in a variety of chronic painful conditions and appears to be responsive to treatment-related change. Formatted in a similar way, the Pain Disability Index (PDI; seven items) provides an alternative to the BPI. It consists of seven questions assessing disability due to pain in the following domains: family/home, recreation, social activities, occupation, sexual behavior, self-care, and life support activities. Each item is rated on an 11-point scale (0 = no disability to 10 = total disability) and the responses are summed. The PDI is also responsive to change following pain treatment.
The Roland-Morris Disability Questionnaire (24 items) was developed from the Sickness Impact Profile (SIP) and tailored for more focused use with chronic low back pain patients. This measure has become one of a select group of standard outcome measures in the back pain literature. Although primarily used for the assessment of function in low back pain, some investigators have used this shorter scale to assess function in heterogeneous groups of patients seen through multidisciplinary programs. Other instruments in common usage include the Chronic Disability Index (9 items), a yes/no checklist covering nine general activities that are typically difficult for people with back pain, such as walking, sleeping, putting on footware ; and the Oswestry Low Back Pain Disability Questionnaire (10 items), a brief scale that provides a percentage score reflecting the amount of restriction that pain imposes on the individual. Scores have been shown to be responsive to treatment.
Sleep
Sleep disturbances are common in chronic pain patients and are known to be risk factors for both the development and exacerbation of pain. There are a number of validated assessment tools available to measure the severity of sleep disorders such as insomnia. The Pittsburgh Sleep Quality Index (19 items) is a widely used and well-validated measure of sleep quality. It assesses disturbances in seven domains of sleep during the past month, including subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep medication, and degree of daytime dysfunction. The Insomnia Severity Index (7 items) identifies severity of sleep continuity disturbance, defined as difficulty: initiating sleep, staying asleep and early morning awakenings, as well as related distress, which are rated on a five-point Likert scale.
Since these measures of sleep patterns evaluate sleep retrospectively, they are prone to bias and error. Daily sleep diaries completed every night before bedtime and in the morning upon awakening can provide more accurate information. Ideally diaries should be collected for at least a week and include the documentation of bedtime, how long it takes to fall asleep, number of nightly awakenings, time spent awake in the middle of the night after initially falling asleep, time of final awakening, and time out of bed. These questions can help determine whether the primary problem is initiating sleep, maintaining sleep, early morning awakening, or poor/irregular sleep habits. It is also informative to have patients rate the quality of their sleep on a scale of 0 (poor quality) to 10 (excellent quality).
Psychological Function and Emotional DISTRESS
The extent of disability in pain patients does not correlate strongly with the extent of physical impairment. The biopsychosocial pain model suggests this discrepancy is related to the psychological, social, and contextual variables that interact with physical factors to determine the individual’s experience with pain and disability. Thus the assessment of psychological function, specifically negative affect, such as depression and anxiety, as well as negative cognitions is an essential component of pain assessment.
There are several commonly used standardized measures for depressive symptoms. The Center for Epidemiological Studies Depression Scale (CES-D; 20 items) was originally developed for use in general-population epidemiologic studies. Respondents are asked to report the frequency with which they have experienced each symptom during the past week on a four-point scale. The CES-D is brief and has excellent psychometric properties, but has also been criticized for possibly overestimating the prevalence and severity of depression among pain populations. The Patient Health Questionnaire Depression Module (PHQ-9; 9 items) is a newer scale that uses criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM) for diagnosing depression, using a 2-week time frame, and can be used as a measure of likely depression diagnosis as well as to track severity of symptoms. The PHQ-9 shows adequate sensitivity, specificity, and accuracy in diagnosing depression in chronic pain populations.
Anxiety is a negative affective experience that can exacerbate the pain experience and complicate recovery. Despite the importance of anxiety in chronic pain, there are few studies validating standardized anxiety measures in chronic pain populations. The Generalized Anxiety Disorder scale (GAD-7; 7 items) is a valid and short scale for screening and assessing severity of anxiety in the general population. Common symptoms of anxiety are rated on a scale from 0 (“not at all”) to 3 (“nearly every day”). The Hospital Anxiety and Depression Scale (HADS; 14 items) is a screening tool for depression and anxiety in medical settings. It is commonly used in chronic pain patients and provides a depression and anxiety subscale with good psychometric properties. An instrument designed to measure anxiety specific to pain patients is the Pain Anxiety Symptoms Scale (PASS; 40- and 20-item versions). The PASS uses a six-point scale and asks respondents to rate the frequency with which they experience several dimensions of anxiety, including somatic, cognitive, fear, and escape/avoidance concerns.
The Symptom Checklist-90-Revised (SCL-90-R; 90 items) is used for assessing psychopathology among chronic pain patients. The SCL-90-R assesses nine different types of psychological disturbance and yields three global measures of distress. This questionnaire is often favored since there is a reduced likelihood of patient resistance due to focus on symptoms; however, it has not demonstrated predictive validity with regard to treatment outcome.
Other instruments are useful when the clinician needs a broader assessment of psychiatric illnesses and personality variables that might impact the functioning of pain patients. The Minnesota Multiphasic Personality Inventory (MMPI) and its successor, the MMPI-2, is the most widely used, and extensively researched, instrument for measuring psychopathology and personality variables. The three core validity scales assess the patient’s response set and motivation. The 10 clinical scales tap dimensions such as concern with bodily symptoms, depression, defensive strategies, rebelliousness and antisocial tendencies, suspiciousness, worry and anxiety, and odd thinking. Additional subscales measure more specific symptoms, traits, and behaviors, including anger, family problems, social alienation, addiction potential, and negative treatment indicators.
Pain-Related Beliefs, Cognitions, and Behaviors
The beliefs and thoughts patients hold regarding their pain can significantly impact their daily functioning and quality of life. In general, the positive or negative content of these cognitions incurs risk or builds resiliency for effectively adjusting to daily life with chronic pain, influencing the impact of pain on mood, social relationships, and other aspects of life.
Coping is a term that typically refers to diverse range of strategies, techniques, and behaviors that people use to manage stressors, including pain, regardless of whether they are successful or not. Some pain-specific coping strategies, like pain catastrophizing (discussed later), are consistently related to a wide range of poor outcomes, and psychological interventions can improve these strategies. Several measures of pain-specific coping are available. The Coping Strategies Questionnaire (50 items) assesses the extent to which patients engage in a variety of cognitive and behavioral coping strategies when they experience pain, including diverting attention, reinterpreting pain sensations, coping self-statements, ignoring the pain, praying or hoping, increasing activity, and perceiving a measure of control over the pain. The Chronic Pain Coping Inventory (65 items) focuses on behavioral strategies of coping that might be encouraged, or discouraged, in a multidisciplinary pain treatment program, including guarding, resting, asking for assistance, relaxation, task persistence, exercise/stretch, seeking social support, coping self-statements, and medication use.
Negative Beliefs and Cognitions
Negative cognitions are the person’s habitually maladaptive ways of perceiving and thinking about situations, and can contribute to a cascade of negative emotions and behaviors. Among pain patients, examples might include a tendency to overfocus on the pain, fearful anticipation of extreme pain, or the belief that any amount of pain signals tissue damage or reinjury, and should be avoided at all costs. Indeed, data suggest that a strong anticipation of pain and reinjury or negative thoughts about pain, referred to as catastrophizing, can lead to fear-related avoidance of activity and increased pain-related disability. These fears can produce a negative reinforcement loop supporting the persistence of avoidance behaviors (e.g., lying down) and functional limitations (e.g., work-related disability).
Several instruments are available to measure various beliefs, attitudes, and expectancies about pain, including some that are multidimensional. The Survey of Pain Attitudes—Revised (57 items) assesses seven pain-specific attitudes, including perceptions of pain control, disability, and harm, as well as beliefs surrounding pain medication, the role of emotions in their pain experience, and the expectation that other people should be more supportive of their pain concerns. The Pain Beliefs and Perceptions Inventory (16 items) taps three dimensions of pain-related beliefs: future expectancies about pain and its persistence, the nature of pain and its symptomatology, and self-blame surrounding pain.
Catastrophizing is a negative cognitive and emotional response to pain and one of the most widely studied psychological constructs in the pain literature. Pain-related catastrophizing is associated with pain, disability, and emotional distress in both cross-sectional and longitudinal studies, as well as with prolonged hospital stay, use of pain medication and treatment outcome. Catastrophizing is most commonly measured using the Pain Catastrophizing Scale (13 items), designed to measure individuals’ tendencies to focus on pain-related thoughts and exaggerate the significance of painful stimuli. It contains three subscales: magnification, rumination, and helplessness. The catastrophizing subscale of the Coping Strategies Questionnaire (6 items) is also commonly used and measures primarily pain-related helplessness. Both questionnaires have been extensively used and validated in various pain populations.
When pain is experienced repeatedly, as occurs in chronic pain, individuals can develop a conditioned fear response to activities or events that may evoke pain. Kinesiophobia is the term for excessive fear of pain and reinjury with physical movement, which can lead to avoidance behaviors and may serve to exacerbate and maintain pain-related disability and decrease engagement in meaningful daily activities. The Tampa Scale of Kinesiophobia (17 items) assesses excessive fear of physical activity related to the perceived threat of pain. Similarly, the Fear-Avoidance Beliefs Questionnaire (16 items) measures beliefs concerning the risk of harm from general physical activities and also from work-specific activities.
Positive Beliefs and Cognitions
Self-efficacy is one’s confidence that they will persist in activities despite obstacles or negative experiences. In the context of pain, it is the belief that one can successfully carry on with daily life despite pain and its consequences. Self-efficacy is consistently associated with pain-related outcomes such as depression, disability, and treatment benefit. A number of questionnaires have been developed to measure self-efficacy in chronic pain patients. The Pain Self-Efficacy Questionnaire (10 items) is widely used and well-validated scales in which patients are asked to rate their level of confidence (0, “not at all,” to 6, “completely”) that they can perform different activities despite their pain. The Chronic Pain Self-Efficacy Scale (22 items) is also a commonly used and valid scale that includes three subscales: self-efficacy regarding pain, physical function, and coping. Patients are asked to rate how certain they are in their ability to cope with their pain and other symptoms, as well as their ability to engage in different activities on a 10-point Likert scale (10-very uncertain to 100-very certain). The Arthritis Self-Efficacy Scale (there are 20-, 11-, and 8-item versions) is one of the most widely used scales for measuring self-efficacy in patients with arthritis. Patients rate their ability to cope with pain and disability as a result of arthritis using 10-point Likert scales (1, “very uncertain,” to 10, “very certain”).
Locus of control refers to an individual’s belief about his or her ability to influence outcomes in life. As applied to chronic pain, locus of control refers to the extent to which patients believe they can influence or ameliorate the intensity and impact of their pain experience. The Pain Locus of Control Scale (18 items) was adapted from the Health Locus of Control Scale (54 items) for this purpose, and may be useful in predicting pain treatment outcomes.
When efforts to control pain are unsuccessful or problematic, an alternative approach is acceptance. Acceptance of pain (and pain-related suffering) is the ability to accept the changing nature of present moment thoughts and emotions without judgment. This approach has been combined with a focus on the pursuit of valued goals and activities in a third generation of interventions called Acceptance and Commitment Therapies. The Chronic Pain Acceptance Questionnaire (there are 20-item and 8-item versions) is a validated scale that measures two dimensions of acceptance: activity engagement despite pain and willingness to experience pain.
Related posts:
Full access? Get Clinical Tree
