Over the past 30 years, we have seen tremendous changes in the diagnosis and treatment of pain. The prevalence of pain is striking.
According to a recent article by Turk and Melzack, despite improvements in medicine, “pain is not well understood and the severity of the pain may not be adequately managed.”
They further note that the central problem in providing appropriate treatment of pain continues to be the inherent subjectivity of the pain experience.
In this installment of the History of Pain, we will examine the psychosocial assessment of pain. As noted in earlier installments of this series, I use subjective data in forming my clinical impressions and treatment recommendations.
However, health care providers should keep in mind that the assessment process is a 2-way experience because the patient also is assessing the provider based on subjective impressions. If the patient is unhappy with their provider or treatment, it can influence treatment outcome.
Both the provider and the patient should keep in mind that pain medicine is not an exact science but is based on a trial and error process.
First Step: Initial Evaluation (Impressions)
Under usual circumstances, the patient then is evaluated by the primary care provider (PCP), who will have reviewed their initial paperwork and incorporate staff subjective impressions before actually meeting the patient.
After the PCP completes the initial evaluation of the History and Physical (H&P), 2 approaches are possible:
- treat the patient with pain medicine and conservative treatment (physical therapy) or
- refer the patient to a specialist for further assessment and recommendations.
If the PCP chooses to refer to a specialist, the PCP will forward the initial evaluation that will include subjective impressions.
The specialist may elect to perform additional tests before they forward their response back to the PCP. This evaluation may include additional subjective impressions as well as objective findings.
The end result is that as the patient’s medical record expands, it includes accumulating subjective impressions that will greatly influence subsequent treatment recommendations. Each participant in the assessment process plays a specific role. In addition, each provider will determine the outcome of initial assessment recommendations.
At this point in the process, the assessment and initial recommendations become part of the trial and error treatment journey.
The patient should be aware that the provider is charting the course of this journey with some of the following goals:
- formulating a differential diagnosis,
- understanding the nature of the patient’s pain,
- evaluating the impact of the pain on the patient’s life,
- assessing physical strengths and weaknesses, and
- measuring response to treatment.
Finally, the provider should be sensitive to the physical and emotional demands placed on the patient by extended assessments.
How to Measure Pain
The measurement of pain presents a number of challenges.
The patient is the only one who can provide information about the intensity of their pain. Throughout the assessment process, patients are asked to rate their pain—usually using a visual analog scale (VAS) from 0-10, ranging from no pain (0) to the worst pain they can imagine (10). In reality, this may be the only measure of pain used in the clinical setting.
There are a number of concerns with this approach… relying on a single measure of pain intensity (eg, VAS), the provider is omitting critical data that maybe obtained through other assessment tools.
Physical Pathology May Not Equate to Pain
There are some clinicians who feel that the only approach to identify the true nature of pain is to demonstrate physical or chemical pathology.
For disability claims, including Social Security, only physical findings—imaging and laboratory results—are used to determine whether a claim should be accepted or rejected.
The reasoning behind this approach is based on the faulty assumption that physical findings are directly related to the pain experience.
Unfortunately, biomedical research has not been able to confirm that the existence of physical pathology and pain are directly related.
- a number of studies have found that significant pathology can exist in individuals who report little or no pain, and
- studies have found significant levels of pain with little or no physical pathology.
Despite these findings, there are still many clinicians who feel that if pain is not associated with physical pathology, then by simple deduction, pain must be psychogenic in origin. Again, as I have pointed out previously, there is no creditable empirical research to support this position.
Most of what we know today about the chronic pain experience is based on a very small and select sample of the overall pain population
Our knowledge base primarily is derived from patients who have been referred to specialized pain programs and not the general population of patients who experience chronic pain.
The role of a pain psychologist is very limited due to a number of factors:
- few psychologists specialize in pain,
- insurance limitations are growing, and
- patients are reluctant to undergo a comprehensive psychosocial evaluation.
Even though IMMPACT was proposed for research in clinical trials, 8 consensus recommendations have been published that support its use in clinical practice. The 4 domains and measures recommended by the IMMPACT study are shown in Table 1.
Behavioral Analysis of Pain
In 1989, I was fortunate to attend a week-long intensive workshop conducted by Wilbur “Bill” Fordyce. Dr. Fordyce was a pioneer pain psychologist, who helped found the pain management program at the University of Washington.17 For me, the most important aspect of the Fordyce workshop was his Behavioral Analysis of Pain (BAP) model. To my knowledge, he never published the BAP, so I will summarize it for the reader.
For Dr. Fordyce, the main purpose of a psychological evaluation was
- to determine if pain/suffering behaviors appear to be controlled by social or
- emotional contingencies or by stimulus control as a consequence of superstitious learning.
…you are looking for associations between pain behaviors and environmental cues (triggers) and consequences.
There are 19 questions included in the full BAP (Table 2).
McGill Pain Questionnaire
The first psychometric test that I am going to review is the McGill Pain Questionnaire (MPQ), which is based on the Melzack & Casey Model of Pain. The initial research was conducted by Melzack and Torgerson in 1971 to assess the 3 major components of the pain experience:
- motivational-affective, and
The MPQ is based on 102 descriptive adjectives that describe different aspects of the pain experience. These 102 adjectives are categorized into 3 major classes and 16 subclasses: sensory, affective, and evaluative
Sickness Impact Profile (SIP)
The most recent version appeared in 1981, and according to the authors, it was developed to measure the impact of disease on both physical and emotional functioning.
It is a straightforward instrument composed of 136 yes/no questions.
The main scales assess
- body care,
- social interaction,
- emotional behavior, and
It also includes independent scales for
- work management,
- recreation, and
West Haven-Yale Multidimensional Pain Inventory (MPI)
This instrument is well respected and widely used, with a focus on cognitive-behavioral aspects of chronic pain.
The 52-item, 12-scale questionnaire is divided into 3 parts.
Section 1 contains 5 scales:
- Perceived Interference of Pain in Vocational, Social/Recreational, Family, Marital/Couple Functioning;
- Support from Significant Others;
- Pain Severity;
- Life Control with Activities of Daily Living; and
- Affective Distress.
Section 2 assesses patients’ perceptions of others perceptions of their pain. Further scales measure negative, solicitous, and distracting responses.
Section 3 assesses patients’ participation in 4 types of daily activities:
- household chores,
- outdoor work,
- activities away from the home, and
- social activities.
Numerous studies confirm that the MPI is psychometrically sound and that it provides comprehensive information that is useful in the clinical setting.
Cognitive behavior therapy (CBT), as a psychological pain treatment, has become the therapy of choice. The role of CBT evolved out of a strong history of behavior therapy that recognized that cognition or thinking was an important component of behavior change.
An important component of the CBT approach is the assessment of the patient’s beliefs about pain.
Maladaptive beliefs now are recognized as a major risk factor for poor response to treatment.
There are a number of instruments available to assess a patient’s beliefs, but one that stands out is the Survey of Pain Attitudes (SOPA). The initial version was published in 1987.25 It has 24 items designed to assess 5 dimensions of pain beliefs:
- pain control,
- pain-related disability,
- medical cures for pain,
- solicitude from others, and
- medication for pain.
Coping with pain is an integral aspect in CBT. In 1984, Lazarus and Folkman defined coping as
“constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.”
It is important to recognize how the patient appraises pain, since it can greatly influence how they cope with it. Is the pain killing me or is it troublesome?
Coping Strategies Questionnaire (CSQ). The CSQ was designed to assess specific coping styles. It designates 6 cognitive and 1 behavioral coping strategy.
Cognitive coping strategies include:
- diverting attention,
- reinterpreting pain sensations,
- coping self-statements,
- ignoring pain sensations,
- praying or hoping, and
The behavioral subscale is: increasing activity.
In addition, there are 2 self-efficacy questions assessing a patient’s perceived control over pain and ability to decrease pain.
Catastrophizing was included in the original CSQ, which focused on a style of reacting to a stressor, including pain.
From a pain perspective, catastrophizing has been defined as “an exaggerated negative orientation toward pain stimuli and pain experience.”
The role of the sympathetic nervous system (SNS) in pain experience has been well documented. In addition, there are many prominent researchers who feel pain is mediated by the SNS.
The first modality mentioned is the surface electromyograph (EMG). It is well accepted that elevated levels of muscle tension plays a critical role in many pain syndromes including headache, temporomandibular joint (TMJ), and low back pain.
The next modality that deserves mention is skin temperature, since it is a valid indication of sympathetic reactivity. In addition, skin temperature/vasoconstriction is associated with stress.
On a practical clinical level, when I introduce myself to a patient, I always pay attention to the patient’s hand temperature
The practical utility of skin temperature feedback is that the patient can leave the thermister on as they go about their day. This has 2 purposes for me in the clinical setting.
- The first is that it builds awareness of the mind/body connection.
- Second, I will use the skin temperature readings in association with the patient’s pain levels.
This feedback helps determine how reactive the patient is outside the office environment.
The third psychophysiological modality is the electrodermal response (EDR) or, in the old parlance, galvanic skin response (GSR).
Skin conductance has been shown to be a good measure of general arousal or sympathetic reactivity. In certain pain syndromes—such as complex regional pain syndrome, phantom limb pain—autonomic arousal, general arousal, or sympathetic reactivity appear to play a central role.
A comprehensive psychosocial evaluation needs to include assessment of the patient’s
- coping ability,
- close supportive relationships, and
- the impact of pain on the patient’s life.
All of these components complement the physical examination so that the “whole patient” can be evaluated and treated in the best fashion available.