A Classification of Pain Patient Behavior

Taxonomy of Pain Patient Behavior – Practical Pain Management – By Ron Lechnyr, PhD, DSW and Henry H. Holmes, MD – Dec 2011 (repost from Feb 2015)

I’m posting this so you can see how doctors view our behavior and what we tell them about our pain. Knowing what we look like from “the other side” can help us avoid falling into one of these categories that cause doctors to dismiss us or view us negatively.

Though all types of physical illnesses and problems have psychological issues that need to be considered in the delivery of services, there are some patients whose response style may confound the diagnostic picture.

When this happens, such patients are often given the label “hystronic,” “neurotic,” or as having a “functional overlay” to their pain or medical problems.  

Others involved in the case … may start to wonder whether the patient has “psychological problems” as the main cause of their difficulties. This results in the patient feeling that caregivers are no longer listening to them and so patient tries to “work harder” to “get others to listen.”

Functional Overlay Syndrome

For practical purposes, functional overlay can be defined as whatever else the patient brings along with their organic (real) pathology. These elements include psychological, emotional, coping, and interactional styles, basically, “the human factor.”

This definition assumes that there are both positive and negative functional overlays. In practice, however, use of the term usually carries a sense of, at a minimum, mild frustration and impatience since the process of diagnosis and treatment are made more difficult.

It is important to understand that the patient’s response and coping style, which results in this overlay, is only an attempt to handle the fear and anxiety of the changes impacting their life and physical functioning.

I’m surprised to see such a compassionate statement here, an acknowledgment that our “previous life” has become unmanageable due to our constant pain.

Involving a psychologist or clinical social worker having a specialty in pain management is critical to mediating treatment and maintaining continuity of care.

It’s critical that the therapist have experience with pain management practices and understand the burden of being in pain much of the time.

Otherwise, you’ll immediately be labeled as an “addict” if you mention taking opioids. That happened to me when I saw a therapist who believed all my troubles (even the pain) were due to an underlying addiction.

However, when I was sent to an “addiction therapist” who had lots of experience with addicted folks, she quickly saw I was not addicted.

The “test” she gave me was to track, in writing, my opioid use. When I returned the next week with a page-long typed document from my ongoing “health diary”, she told me that in the years of asking patients to track their drug/medication use, I was the first one to have done it. Apparently, addicts don’t keep health diaries.

My written record also helps me with doctors. When they see I’m documenting exactly what I’m taking, how much, when, and what for, they are reassured that I’m not doing anything “stupid” with my opioids. That must make them less worried about prescribing for me.

The involvement of a mental health professional should not be seen as a way of dismissing the patient’s complaints or problems, but rather as an adjunct to successful treatment.

The following sections provide a discussion on the significant and varied aspects of patients exhibiting functional overlay, including perspectives on understanding motivations, varied ways of assessing, treating, and viewing such patients to improve outcomes.

The taxonomy of eleven patient types was amassed over years of success and failure, and trial and error. It is meant to be practical rather than exhaustive, yet should provide utility to practicing physicians, psychologists, evaluators, legal representatives, insurers, and others in addressing this patient population.

1. The Frightened Patient

The patient’s internal images of what their symptom means are perceived in catastrophic terms. As a result, the patient may talk too much, ask too many questions, be overly-dramatic, emotional, and have a sense of on-going panic and reactivity that makes exposure to this patient somewhat overwhelming.

The need is for in-depth education directed at changing the patient’s perception of the problem to one which is less threatening and more under personal control.

2. The “Please Hear Me” Patient

This patient values relationship above technical information and, before developing confidence in any treatment, will need to be treated as an individual. [and otherwise, not? -zyp]

The physician needs to listen carefully, examine carefully, and take the time to develop a relationship. These patients can be very grateful and loyal if handled appropriately.

3. The “I Hurt Everywhere You Touch” Patient (Low Pain Tolerance)

This patient is difficult to examine; light palpation and examination procedures cause greater than expected pain and resistance. The patient exhibits a poor discrimination for the severity of their felt sensations. The physician finds exact diagnosis is often difficult or impossible.

The problem is one of lowered pain tolerance.

Close questioning usually discloses the symptoms of endogenous depression with

• exhaustion,
• sleep disorder,
• mood and concentration difficulties.

These patients often expect a great deal of themselves and may exhibit embarrassment, a fear of having a psychological problem, or a sense of inadequacy.

…some patients may be genetically programmed to feel things more intensely. This does not reduce the reality of the organic problem.

This sensitivity, and the propensity to suffer from anxiety and depression, is part of the genetic fallout from Ehlers-Danlos Syndrome.

The physician should express concern that the patient’s pain or medical problem has been so severe that they have become exhausted.

Antidepressants should be prescribed in appropriate dosage with adequate explanation to ensure compliance. The physician should reassure the patient that as their sleep and natural resistance to pain improves, treatment will continue towards resolving the pathology

4. The “Overwhelmed” Patient

This patient may present similarly to the low pain tolerance patient. The difference is that the stressors are more external — marital, financial, children’s behavioral problems, death in the family, etc. — and have grown to a crisis proportion with the patient becoming overwhelmed.

The physician must explain the medical problem in relationship to their severe, understandable stress; treat the medical condition, but explain that it will not resolve without simultaneously treating the “cause.” Connecting the patient with resources for support and problem-solving to regain control and stability of their situation is the focus.

5. The Angry/Blaming Patient

This patient expresses anger either directly or indirectly which, in turn, interferes with establishing or maintaining an adequate doctor-patient relationship. It is important to note that anger is usually a “smoke screen” covering other human emotions and concerns. Anger is a communication that calls for understanding at a deeper level.

Questioning and listening to the patient to determine what the anger is about and asking what the patient wants can help diffuse anger. Anger can be a defense and you may learn what the patient fears and wants (instead of what he/she may have gotten previously that did not meet expectations).

Handled appropriately, angry patients often become cooperative patients who see their physician as a partner in the treatment process. Often the anger of a new patient is the result of feeling that they were not heard or taken seriously by other physicians.

6. The Somatizer

This patient type describes a condition that is emotional (“dis-ease”) expressed physically or somatically. The intensity of the focus on symptoms reflects the intensity of the emotional disturbance

Frequently, such patients have had poor childhood emotional training or have sustained significant trauma and abuse. What is important here is that the patient is actively asking for help, even though the help needed may be very different than what the patient believes.

Listening carefully to the imagery of the patient’s symptom description for clues (most somatizers are not difficult to spot!) and emanating acceptance and a non-judgmental attitude towards the person and their condition is very helpful in this situation.

The claim that “most somatizers are not difficult to spot” is a surprise since so much of the anti-opioid campaign is focused on people faking pain to receive opioids.

The myth that this patient type is untreatable is presumed by most physicians and insurers but, in reality, can successfully respond to a pain management psychological approach to treatment.

Getting the patient to accept psychological intervention is tricky but can be done if the patient feels accepted and sees the referral as part of a coordinated approach to their care

7. The Passive Patient

This patient does little to actively participate in their own care. Many varieties of behavior may be involved including failing to follow through with treatment — even when agreed to — appearing helpless, overwhelmed, incapable of acting on their own behalf, or offering numerous excuses usually based on being controlled by others or by circumstances.

The physician’s attitude must be one of respect and firm expectation that the patient learn to manage their own problems.

The agreement, simply stated is: “I’ll provide these medical services, provided you follow through with the recommendations which only you can do for yourself: I’ll take one step for each step of yours, but no more.” This attitude defines the treatment relationship as adult to adult rather than adult to child.

8. “Secondary Gain”/Malingering

For some it may become more comfortable to remain ill than to recover or adjust. Illness may “gain” the patient attention and care they don’t otherwise receive, or it may relieve them of responsibilities that were burdensome or overwhelming.

True malingering is rare, while secondary gain factors are common and will remain so as long as people lack viable options or the confidence to successfully make changes in their lives.

It is important to understand that secondary gain factors are ones the patient is not aware of on a conscious level, yet may strongly motivate a patient towards specific goals of an unconscious psychological nature. Primary gain factors, by comparison, are those the patient is very aware of trying to obtain, such as increased, or continuing, compensation. This latter behavior is not as frequent as one might think in patients with disability and illness.

Except in the case of drug dependency, it may not be therapeutic to directly confront the patient unless there is a strong therapeutic alliance.

Mobilizing resources, particularly referring the patient to a pain psychologist, or a pain center program, can provide the patient with more options and choices for coping more effectively.

This is preferable to the “good swift kick” approach which will often simply land the patient in another physician’s office schedule without any awareness or resolution of the problem.

I’m shocked by how paternalistic this author is. Such a “good swift kick” technique applies only to children, not adults. Just because he’s a doctor doesn’t allow him to treat us like irresponsible little children.

9. Hysterical Personality/Over-dramatization

These patients simply express themselves with greater vigor, color, and flamboyance. This is often a learned behavior, and it can be cultural. The patient believes that this is what is required to get their physician’s attention and proper treatment. This is not personal. They present these same behaviors in most aspects of their lives.

It helps to have seen the patient over a period of time so that the stability of the style is apparent. The task is to simply accept (and perhaps even enjoy!) this manner of self-expression.

The patient needs to be educated as to why their manner of approach may get them less of a positive response from physicians.

It is important to remember that real physical problems can exist even with dramatic presentation of symptoms.

10. Major Psychiatric Disorders

Obviously, such patients should have a combined medical and psychiatric/psychologic approach both for their own benefit and the physician’s comfort

The goal is to bring the patient into psychiatric or psychological management while simultaneously providing appropriate medical care.

11. The “Normal” Patient

Many normal patients, faced with an injury or illness, may react in uncharacteristic ways from their usual manner of relating

When patients are in dependent positions they can regress in their functioning. It is tempting to assign the obvious psychopathology as the cause of the problem, yet it is important to remember that each of us, when under stress, can be “difficult” patients who react in immature ways in order to defend against “attack” and vulnerability.

The physician should explain the issues of crisis and trauma and its impact on the normal person, including the stages of grief and how we all react to illnesses

The goal of psychological intervention, in this instance, should concentrate not so much on diagnosis as on assisting the patient to learn active self-care management skills.

Proper Role of Psychological Testing

The MMPI-2, which was first developed in 1939 and later updated and revised in the 1990’s, provides a tool in understanding psychopathology, behavioral issues, and problems in functioning

Utilizing the MMPI-2 for other purposes, however, such as trying to discredit a finding of “permanent pathology” in a patient has no validation in research and misconstrues the purpose of this useful evaluative tool.

Some useful insights gained from the MMPI-2:

1. psychiatric disorders found in chronic pain patients show improvement with pain treatment,
2. lack of problem-solving pain management with sole focus on immediate relief creates further physical problems, reduced functioning and fosters anxiety about future pain problems,
3. 40% of chronic pain patients suffer from depression as a result of living with chronic pain, rather than their depression causing chronic pain,
4. cognitive behavioral therapy is superior at decreasing pain intensit and improving pain coping,
5. pre-surgical psychological evaluation can help improve surgical outcomes, especially if the focus is on assisting the patient in understanding how their present functioning may hinder any type of intervention, and
6. most importantly, understanding that the MMPI-2, or any other psychological test, should only be used as a guide for treatment interventions, rather than as a tool having as it’s sole focus psychopathology.

Functional overlay is just as challenging an area of medicine and psychology and deserves the same disciplined differential diagnosis and specific treatment approaches — as well as an acknowledgment of limitations.

A patient with several interacting medical conditions needs treatment approaches that honor each. Functional overlay can be viewed simply as a second medical condition which requires that we modify our approach to the first and treat the combination.

The challenge in managing these cases is quite often a physician’s personal reactions to these patients’ psychological response style. It is hoped that this article will provide the physician, psychologist, and others, with a guide to understand and respond therapeutically to these complex syndromes.