Pain is the most common complaint encountered by a primary treating physician (PTP). Although most pain is acute and resolves with treatment of its underlying cause, all pain problems have emotional as well as physical components. Treated ineffectively, the emotional components of pain mount steadily until the emotional symptoms loom over all aspects of the patient’s life.

Effective chronic pain treatment relies on well-informed and well-organized primary care which can intervene early to help lessen the multiple factors that determine the extent of potential pain and disability. We will outline some critical psychological and social factors that can block effective chronic pain treatment. We believe that regular screening for these factors, followed by appropriate referrals for mental health treatment can enhance recovery and reduce treatment costs.

Depression and anxiety are two of the most important disorders for the PTP to assess in chronic pain patients. Depression creates rehabilitation failure by causing low motivation, poor morale, low energy and hopelessness. Highly anxious patients become incapacitated with fear and embarrassment.

At the Texas Pain Medicine Clinic, we have found that 23% of our patients experience panic and 74% suffer depression. Panic-afflicted patients tend to avoid certain rehabilitation situations and sometimes become too overwhelmed to leave their homes. Suicidal impulses occur in both groups and should be routinely assessed by the PTP.

There are many good screening questionnaires to alert the PTP to these problems.

The Beck Depression Inventory®-2 (BDI®-2) and the Beck Anxiety Inventory (BAI®) are two popular questionnaires that can each be completed and scored in about six minutes. Both have good psychometric properties and are easily scored. These screens have the problem of false positives due to their inclusion of physical problems that can inflate scores.

The Hospital Anxiety and Depression Scale (HAD) contains 14 questions that are relatively free of physical symptoms. Although it can be completed quickly, it is more difficult to score than the BDI-2 and BAI.

A newer and promising screening test is the P-3® (Pain Patient Profile) assessment. This 44-question screener requires 15 to 20 minutes to complete and is specifically normed on pain patients. It is more difficult to score but a scoring software program can produce faster results.

• Personality Disorders

Chronic pain patients have higher rates of personality disorders than the general population. Paranoid, passive-aggressive and borderline are the most common disorders. Patients with personality disorders can be difficult to treat, with resulting poor outcome. While diagnosing a personality disorder is complex, the PTP can be aware of a referral need by certain basic observations.

For example, patients with personality disorders can be unrealistically demanding or irritable, highly insecure, unusually suspicious or mistrustful and/or passive. They may exhibit intense, unstable moods and sometimes engage the PTP in a tumultuous relationship. Sometimes patients with personality disorders have a history of sexual or physical abuse in childhood or past relationships. The PTP should inquire about an abuse history due to the associated risk for treatment failure without proper interventions.

• Cognitive Problems

Cognitive problems ranging from concentration / memory problems to disorganization and/or psychosis, can interfere with treatment. Pain patients with cognitive deficits can mimic patients with mild to moderate traumatic brain injuries. Cognitive problems can result from a myriad of factors such as depression, anxiety, insomnia, medication side-effects and the pain itself. Severe cognitive problems can lead to improper medication use, impaired medical compliance, and general inability to problem-solve effectively and/or organize daily activities.

The PTP can assess these problems by interviewing patients and family members. The BSI® (Brief Symptom Inventory), which takes about 10 minutes to complete, can reveal problems in thinking as well as depression and anxiety. This test is most useful as a screen of general emotional distress.

The Mini-Mental™ State Examination, a quick and widely used oral questionnaire to assess cognitive mental status, requires some training and can take time to administer and score, depending on the degree of impairment.

•   Job and Family Issues

Secondary gain issues and reinforcement of the patient’s disability by family members are very important factors for the PTP to consider. Job dissatisfaction is a powerful disincentive for recovery. Family members that are overly helpful to the point of reinforcing disability can solidify the patient’s sick role. Malingering or symptom exaggeration can emerge and are often associated with psychosocial issues.

Some patients worry about mistreatment from co-workers or bosses if they return to work. Others worry about re-injury, demotion or joblessness. Emotionally overwhelmed patients often experience increased physical symptoms due to unconscious somatization. Unexpressed or unexperienced emotional problems can re-emerge through increased pain and excessive disability. The PTP should consider a mental health referral when these factors are evident and physical symptoms exceed medical findings.

•   Overuse of Medication

Persistent medication overuse may indicate the need for a mental health referral. Excessive use of alcohol or drugs is a signal of impending treatment doom. Patients overuse medications for a number of reasons beyond the scope of this overview, but, in general, overuse of chemicals can signal that the patient is emotionally and/or physically overwhelmed. Patients can use various substances for energizing or calming effects as an attempt to function at a level beyond their physical abilities. Their mentality can become "the more medication the better" with poor understanding that substance abuse is a problem. The result can be more pain, worsened physical problems and impaired overall functioning and coping.

•   Overall Functioning

Finally, the PTP can use two brief questionnaires to assess overall functioning. The HSQ® 2.0 (Health Status Questionnaire 2.0) requires about 5 to 10 minutes and has various uses, including tracking progress and screening. Although its use as a screening device is not yet established, it can be useful. The Multidimensional Pain Inventory (MPI) is a well-known pain assessment questionnaire. We are currently investigating the validity of an 8-question, abbreviated version of the MPI that would potentially identify patients coping in a "dysfunctional" manner and signal a need for a more complete mental health evaluation.

Effective treatment of chronic pain patients often involves looking at other underlying factors. Screeners can help the PTP determine whether psychological referral is in order, and can provide the PTP with the knowledge needed to help develop an effective treatment plan.

 Robert Freedenfeld, PhD, is a clinical psychologist and a diplomate in pain management from the American Academy of Pain Management. He is the Director of Clinical Research and Training at the Texas Pain Medicine Clinic, Dallas, Texas.

  R. Sanford Kiser, MD, is a physician and Medical Director of the Texas Pain Medicine Clinic. He is board certified in psychiatry and sub-certified in pain management. He is president-elect of the Texas Society of Psychiatric Physicians and President of the Greater Chapter of the Texas Pain Society.

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