Why would I ever need to see a psychologist for my pain?

We know that the experience of pain is influenced by culture, anticipation, previous experience, various emotional and cognitive contributions, and by the situational context. Reactions to stimuli that produce pain vary among people and even for the same person at different times. Nociception (pain signals sent to the brain) is a sensory process. The experience of pain is a perceptual process that requires attention to and interpretation of this sensory input. Sensation does not equate to perception in a 1:1 relationship! Therefore, pain is a subjective experience that is dependant upon a person’s perception of pain signals.

Why do I need a psychological evaluation for Pain? Perhaps the simplest way of answering the question, "Why are psychological evaluations important for injured patients?" is to say that it is an accepted part of general clinical practice. The most widely accepted definition of pain is that developed by the Taxonomy Committee of the International Association for the Study of Pain. It describes pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage." Its definition goes on to note that:

• Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience which we associate with actual or potential tissue damage. It is unquestionably a sensation in part or parts of the body, but it is also always an unpleasant and therefore also an emotional experience... Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain... [Pain] is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

Psychological factors also associated with the onset of pain disorders. The National Institute of Occupational Safety and Health (NIOSH) is a part of the Center for Disease Control in the Department of Health and Human Services. After extensive study, NIOSH concludes that psychosocial factors have a role in the onset of musculoskeletal disorders:

• While the etiologic mechanisms are poorly understood, there is increasing evidence that psychosocial factors related to the job and work environment play a role in the development of work-related musculoskeletal disorders (MSDs) of the upper extremity and back.

The North American Spine Society is the parent organization of Spine, perhaps the most prestigious journal on the orthopedic care of back and neck injuries. NASS has spent years developing clinical guidelines for treatment of these injuries, and these protocols are internationally recognized. Although they were developed by orthopedists, these guidelines strongly advocate the role of psychology. NASS suggests that for "Phase II" patients (20-30% of patients), a psychological consultation is often warranted for the purpose of preventing psychosocial deterioration or address return to work issues. For "Phase III" patients (5-8% of patients), active multidisciplinary treatment including psychology is advocated to effect recovery or reduce disability. It is the position of NASS that:

• Chronic pain is now understood as a complex psychophysiological behavior pattern ... While intensive rehabilitation approaches to spinal disability present society with high short-term costs, long-term benefits of such treatment approaches ensue because of decreased long-term indemnity and medical costs, reduced incidence of permanent injuries, and improved job performance.

Along these same lines, the American Academy of Pain Medicine has produced a consensus statement entitled "The Necessity for Early Evaluation of the Chronic Pain Patient." This statement notes that:

• The diagnosis and management of chronic pain is a complex process requiring intensive, comprehensive, and interdisciplinary services for optimum treatment outcomes. Thorough and effective pain evaluation and control must be the primary goals.

What are the chances that a pain patient has a psychological problem? Those with chronic pain are at risk for a variety of mental health problems. Mental illness is noted at a much greater prevalence in pain patients. Polatin et al. (1993) found that in their sample that 77 percent of their patients met lifetime diagnostic criteria for some form of mental illness even when pain disorders were excluded. They also found that 59 percent demonstrated current symptoms for at least one psychiatric diagnoses which is significantly higher than lifetime and current rates of mental disorders in the general population (29-38 percent and 15 percent respectively). The most common diagnoses in this study were substance use disorders and anxiety disorders. Fifty-one percent of the sample met criteria for at least one personality disorder. Substance use disorders and anxiety disorders were likely to precede chronic low back pain whereas depressive disorders were likely to follow low back pain. Other estimates of the percentage of chronic pain patients with a diagnosable psychological condition range from 86.5% (Katon et al, 1985) to 90% (Large, 1986). Furthermore, 40% (Large, 1986) to 59% (Fishbain, et al 1986) of these patients were diagnosed with a personality disorder. Patients suffering from chronic lower back pain have higher incidence of Major Depressive Disorder, substance use disorders, and personality disorders than those with acute low back pain. In contrast, those with acute pain are more often diagnosed with anxiety disorders. Anxiety is considered to be a common reaction to acute pain while more disabling psychopathologies are associated with chronic pain. Anger is also associated more with chronic pain; however, current diagnostic classification systems exclude anger disorders.

What does my head have to do with anyting? The problem is my physical condition! The straight answer is that psychological variables have been found to be better predictors of pain and disability chronicity than physical variables.

• A research team led by Stanley Bigos, M.D. at the Boeing Plant in Seattle found that psychological factors played the dominant role in determining who would file a Worker's Compensation claim for back pain (Bigos, et al., 1992). About 100 different variables were explored, most of which were medical in nature. Despite this, the only factors found to predict who would file a Worker's Compensation claim for back pain were job dissatisfaction, hysterical personality traits and antisocial personality traits.
• Psychological factors correctly predicted 91% of the time which back pain patients would recover from an injury and which would go on to become disabled (Gatchel, et al., 1995).
• It was found that psychological variables alone predicted delayed recovery accurately 76% of the time (Burton, et al., 1995).
• In contrast, commonly used medical tests have not demonstrated much predictive validity . In a study of the MRIs of 98 "normal" persons with no back pain symptoms, 52% had bulging disks, 27% had a protrusion, and 1% had an extrusion (Jensen, et al., 1994).
• One study compared lumbar surgical outcome for adult patients, some of whom reported being abused as a child and others who did not. The persons who reported having not been abused as a child had exhibited a 95% successful surgical outcome. In contrast, the persons who reported having been abused as a child exhibited only a 15% successful surgical outcome (Schofferman, et al., 1992).
• A meta-analytic procedure was used to determine the relation between disability compensation and pain. A total of 157 studies on this topic were reviewed, and comparisons were made on the basis of 3,802 pain patients and 3,849 controls. The results indicated that compensation is related to increased reports of pain and decreased treatment efficacy (Rohling et al, 1995).
• In a World Health Organization study of 26,000 subjects in 14 countries, it was found that physical disability was more closely associated with psychological factors than it was with medical diagnosis (Ormel, et al., 1994).
• An article in JAMA reported that patients treated in a functional restoration treatment program for chronic low back pain and were compared with 72 patients not treated. A two-year follow-up that 87% of the treatment group was actively working after two years, as compared with only 41% of the nontreatment comparison group. (Mayer TG , et al, 1987)
• When psychological risk factors are assessed and treatment in a functional restoration program is structured to address these difficulties, then patient psychological difficulties interfere less with outcome. (Gatchel RJ, et al, 1994).

What increases my risk for developing chronic pain? Factors that place patients at risk for developing chronic pain include the presence of non-organic signs, evidence of alcohol and/or drug abuse, avoidance anxiety, PTSD, depression, anger, history of physical or sexual child abuse or substance abuse in caretaker of the family, family instability, presence of specific personality traits/disorders, somatization traits, poor interpersonal relationships, arrests, anger at employer, history of poor job performance, unstable work history, number and intensity of pain behaviors, neuroticism, and health preoccupation.

What is cognitive behavioral therapy (CBT) and how does it work? The CBT model incorporates pain sufferers fear avoidance, contingencies of reinforcement, expectations, and contextual factors of the situation into an integrated solution to chronic pain and suffering. People learn to predict behaviors based on experiences and information processing. All of us filter information through our own expectations, belief systems, and schemata and react accordingly. CBT emphasizes a reciprocal relationship between the person in the environment.

Assumptions of CBT with Pain Patients (from: Turk, 2002):

1) People are active processors of information rather than passive reactors to environmental contingencies. Anticipated consequences become as important as actual consequences.

2) Thoughts elicit or modulate affect and physiologic arousal, most of which serve as an impetus for behavior. Conversely, affect, physiology, and behavior can instigate or influence one’s thinking processes. We are complete people, and no part of ourselves is separate from another. " In a real sense, people create their environments." (Turk, 2002, P. 140).

3) Behavior is reciprocally determined by both the environment and the individual.

4) People have learned maladaptive ways of thinking, feeling, and responding so successful interventions are designed to alter behavior should focus on maladaptive thoughts, feelings, physiology, and behaviors and not one to the exclusion of the others.

5) Because people are instrumental in developing and maintaining maladaptive thoughts, feelings, and behaviors, they are, can be, and should be considered active agents of change of their maladaptive modes of responding. People cannot consider themselves to be helpless pawns of faith; rather, they should become active in caring and learning more effect of modes of responding to their environment and their problems.

Stimuli–> schema –> thoughts –> perceptions: People engage in a meaning analysis.

Example: A patient may have incorporated cognitive schemata that he or she is seriously disabled, that disability is a necessary aspect of pain, that activity is dangerous, and that pain is an acceptable excuse for neglecting responsibilities. This person will likely demonstrate maladaptive responses to pain and report a significant disability status. Through the process of stimulus generalization, this patient may avoid more activities and become more and more deconditioned and disabled.

Cognitive interpretations also affect how patients present symptoms to significant others including health-care providers and employers. These communications may even elicit responses that reinforce pain behaviors and impressions about the seriousness, severity, and on controllability of the pain. Behavior, feelings, thoughts, and biology are all interconnected. What influences our behavior will influence all other realms. Psychologists using a CBT approach emphasize thoughts as the primary targets for psychological interventions. Thoughts are relatively easy to identify but change on a moment by moment basis. The elegance of the CBT model is that changing unhealthy thoughts to healthy thought changes unhealthy feelings, behaviors, AND biological processes to healthier responses!

For example, medical science has shown that antidepressant medications and CBT result in similar effects. Brain scan technologies indicate that the areas of the brain undergo changes following cognitive therapy. Changing your thoughts is the equivalent to changing your brain. Cognitive therapy generally may take 1-2 more weeks longer than medication to be effective; however, the cognitive therapy leads to greater improvements in more people due to decreased attrition and better tolerance of treatments, and these changes are more resistant to relapse than medication therapy alone. Cognitive therapy techniques ultimately save time, effort, and money. People that learn to use CBT techniques become skilled self-monitors, and they begin to pay a great deal of attention to the way in which they think about things. They appreciate the power of thinking, and the cumulative effects of specific thoughts over time. They learn to dispute and challenge thinking errors as they occur. This leads to some immediate relief as well as to cumulative benefits over time. By exercising CBT techniques consistently over time, you will change your automatic unhealthy thoughts into automatic healthy and powerful thoughts.

What is CBT like? What will I do?

CBT is problem solving oriented, educational, collaborativen, and supportive. People practice consolidating skills in the clinic and at home, and they are encouraged to express thoughts and feelings so they may learn to better control those that impair their rehabilitation efforts. Patients learn to address the relationship between thoughts, feelings, behavior, and physiology. Tthey also learn how to anticipate setbacks and how to deal with them.

What are the Goals of a Cognitive Behavioral Approach?

Specific goals of CBT are to:

• Re-conceptualize the view that the chronic pain is not overwhelming, it is manageable. This provides for a more benign view of the problem, it translates physical and psychological symptoms into difficulties they can be pinpointed and addressed, and it teaches the patient that problems are amenable to solutions. This fosters hope, positive anticipation, and the expectancy for success.
• Convince patients that the skills necessary for responding to problems more actively will be included in treatment
• Reconceptualize patient ideas that passive and reactive approaches are useless and that active and resourceful approaches lead to success
• Ensure that patients learn how to monitor their thoughts, feelings, behaviors, and physiology.
• Teach patients how to use and when to use adaptive coping behaviors required for healthy adaptation to pain.
• Encourage patients to attribute success to their own efforts.
• Anticipate problems and discuss these as well as ways to deal with them

Cognitive behavioral therapy sessions are structured and include specific elements. The following list describes the basic structure of the CBT session.

• Check mood
• Check pain level
• Check on activity level and changes in functional abilities
• Discuss important points of previous session
• Set current agenda
• Review homework
• Discuss agenda items
• Establish new homework assignment
• Provide summary of session
• Elicit patient feedback as to what is helping and what is not
• Give final summary and feedback to the patient

What do you mean I’ll have homework? Performing therapy homework is essential for success as it helps people to take what they learn in session out into everyday life. Homework typically includes activities that:

• assess problem areas in life
• assess typical responses of significant others to pain, pain behaviors, and functional limitations
• help make the patient and significant other more aware of factors that exacerbate and alleviate suffering
• help patient and significant others identify maladaptive responses to pain and pain behaviors
• consolidate use of coping skills, communication skills, and physical exercises
• increase activity levels
• illustrate how progress can be made in light of suffering
• reinforce self-efficacy
• identify impediments to self-management
• assess clinical team in evaluating progress and in modifying goals

Studies Supporting Efficacy: Does this stuff really work? Again, the simple answer is yes. Psychological treatments for chronic pain conditions do work. Research into the area of therapeutic effectiveness shows that:

• Multidisciplinary pain treatment programs that incorporated cognitive-behavioral therapy and behavior therapy approaches were significantly more successful than unimodal treatment and no treatment controls (Cutler et al, 1994; Flor, Fydrich & Turk, 1992).
• A review article published in the Journal of the American Medical Association concluded that there was "strong evidence" for the efficacy of behavioral interventions in managing pain (NIH, 1996).
• A meta-analysis reviewed 33 studies examining the effectiveness of behavioral treatment of chronic pain (Morley, Eccleston, & Williams, 1999). The data indicated that behavioral treatments are effective in reducing the experience of pain and in improving coping skills. These results supported that idea that behavioral treatment is superior to standard alternative treatments in reducing pain and increasing cognitive coping. Behavioral treatment is alternative to waiting list controls on a number of dimensions, including pain level, mood, activity, and functioning.
• In a 1998 article on "empirically supported treatments" in the area of health psychology, Compas and colleagues used standardized criteria to review the literature; they concluded that behavioral and cognitive pain management treatments tend to produce clinically significant improvements in both psychological and physical functioning in individuals with a variety of chronic painful conditions, including back pain, migraine, arthritis, and irritable bowel syndrome.
• Patients who respond to their pain with active coping strategies (e.g., stretching, relaxation, exercises, cognitive reframing) tend to have a better adjustment than patients who utilize more passive coping strategies (inactivity, helplessness, hopelessness) (Caudill, 1995; Fordyce, 1988; Fordyce, Brockway, Bergman, & Spengler, 1986; Jensen, Turner, Romano, & Karoly, 1991).
• By 1994, there were 15 studies supporting the use of cognitive therapy for tension-type headaches. It appears to lead to an approximately 53% reduction in total headache activity (Bogaards & ter Kuile, 1994; McCrory, Penzien, Rains & Hasselblad, 1996).
• In a direct comparison, CBT was more effective than EMG biofeedback and relaxation for people who were also attempting to deal with high levels of daily stresses (Tobin, et al., 1988).

How will I know that CBT works?

It is important to track improvements. Dr. Williams includes outcome measures in his treatment of chronic pain conditions. The following case examples illustrate how this process is employed.

CASE EXAMPLES

"Dale"

Diagnostic Impressions: DSM-IV-TR

Axis I Major Depressive Disorder, Recurrent, Moderate

Pain Disorder due to a General Medical Condition with Psychological Features

Opioid Disorder, NOS (Habituation and Tolerance)

Axis II Avoidant, Depressive, Dependent, and Negativistic Personality Features

Axis III Lumbar Disc Disease, Radiculitis, Post Laminectomy Syndrome, Depression, and Asthma

Axis IV Legal Problems (Worker’s Compensation), Financial Problems, Pain, Problems with

Social and Primary Support

AXIS V GAF = 45-50 (at intake)

Case Summary.

Dale presented as a 5'3", 156 lb., 29-year-old African-American male who reported that he was injured on the job. He reported that he had a prior back surgery and that he was taking Neurontin, Effexor, and Lortab. Dale is a high school graduate with four years of college. His family history is marked by substance dependency among second-degree relatives on his mother’s side. He denies familial history of mental health problems, and he describes his family in positive terms. Dale has no legal history. He has a stable work history. He presented for a psychological evaluation to assist with the medical treatment of his chronic pain. Medical diagnoses provided with the referral included lumbar disc disease, radiculitis, post laminectomy syndrome, depression, and asthma. Dale’s thought content was marked by a preoccupation with his somatic functioning, and his thought processes were intact logical, and coherent. He presented with signs of depression, somatization, and opioid tolerance. He did not report a history of psychological markers of addiction. Pain assessment measures revealed that he reported more depression, anxiety, and somatic complaints than the typical pain patient, and that there was a significant emotional overlay to his pain complaints. Personality assessment with the MMPI-2 resulted in a valid profile showing excessive somatic concerns, significant malaise, paranoia, and depression. Further, specific and generalized fears were also endorsed. The psychological evaluation was followed by one feedback session to provide results of the evaluation and an orientation to cognitive therapy. He participated in weekly group therapy sessions (structured pain management treatment group where the patient had a manual provided) and individual therapy sessions for 18 weeks. Group and individual attendance was marginally adequate at first, but improved once he was adequately engaged in treatment. Medication changes included the discontinuation of Lortab. In therapy, he was cooperative, active in his own care, and responsive to cognitive interventions but less so to relaxation exercises and clinical hypnosis.

OUTCOME ASSESSMENT: Baseline and outcome measures were taken using the Pain Patient Profile-Third Edition. This is a psychological assessment designed to measure levels of depression, anxiety, and somatization. It is normed on community and pain patient samples. Testing shows that Dale left therapy with significantly lower levels of depression, anxiety, and somatization than he noted at baseline assessment. These changes occurred even with the discontinuation of opioid treatments.

"Flo"

DIAGNOSIS: DSM IV-TR

Axis I Major Depressive Disorder, Single Episode, Moderate to Severe,

Generalized Anxiety Disorder, Mild to Moderate

Pain Disorder Due to a General Medical Condition with Psychological Features

Axis II Schizoid, Obsessive-compulsive, and Avoidant Personality Features

Axis III Left Shoulder Joint Pain, Chronic Low Back Pain, Diffuse Myofascial Tenderness, Obesity with Deconditioning, Hypertension, and Coronary Artery Disease

Axis IV Problems with access to health care services (under-treatment of psychological needs), Problems with Social and Primary Support, Unemployment, Chronic Pain, Legal Issues (Worker’s Compensation)

Axis V GAF = 55 (at intake)

Case Summary. Flo presented as a sullen and emotionally brittle 28 year old, 233 lb. 5 ft. 3-inch Caucasian female with a chief complaint of insomnia and chronic pain following a work related injury. She was taking the following medications: Talwin, Vioxx, Flexaril, and Lopressor. Flo was born to an intact family, and she dropped out of school in the 11^th grade. She described her family in positive terms, and denied any family history of mental health problems or substance dependency. She was never victimized by physical, sexual, or emotional abuse. She is married, with two sons and she lives with her husband. She has no legal history, and she had a stable work history prior to her work related accident. She is followed by a physician for her pain management needs. She has never been hospitalized for psychiatric reasons, and she has had no prior back surgery. Flo was cooperative throughout the interview. Her thought content and processes were intact, logical, and coherent. Mental status examination revealed that she was experiencing symptoms of pain, depression, sleep problems, and anxiety. Pain assessment using the P-3 revealed that she was experiencing higher than average levels of depression and somatization than the typical pain patient. Personality testing with the MMPI-II revealed that she was struggling with symptoms of depression and anxiety, and that under stress she is likely express emotional pain through somatic channels. The results of the MCMI-III revealed Schizoid, Obsessive-compulsive, and Avoidant Personality Features. No overt personality disorder was noted. A psychological evaluation was followed by one feedback session to provide results of the evaluation and an orientation to cognitive therapy. She participated in weekly group therapy sessions (structured pain management treatment group–manual provided) and individual therapy sessions for 12 weeks. No medication changes were made during the course of her care. In therapy, she was cooperative, active in her own care, and responsive to both cognitive interventions, relaxation exercises, and clinical hypnosis. She never became compliant with her pain log, but she did practice relaxation exercises, journaling, activity scheduling and pacing, behavioral assignments (returning to hobbies, going outside more frequently, walking, etc.), and monitoring of cognitive distortions. She joked about how acutely she watched her language.

OUTCOME ASSESSMENT: Outcome was again measured with the Pain Patient Profile-Third Edition. Results show significant improvement in all areas assessed even though no medication changes were made during the course of care.

Note. Of course, therapy is not always effective, and outcomes depend greatly on the effort of the patient in the therapeutic process. We have discharged patients successfully after as few as eight sessions, and we have seen others in therapy for over a year with only minimal improvements. Those that benefit from care share a few commonalities: They are active in their own care; they are motivated to change, they practice what is taught in session at home, and they are able to overcome feelings of anger, helplessness, and hoplessness by coming to peace with the unfairness/injustice of inherent in losing functioning, money, etc. because of an injury.