Chapter 11. Behavioral and Psychological Aspects of Pain

Question 1

833. Primary affective symptoms that are present
     with chronic pain
     (A) generally resolve when the pain is treated
     adequately
     (B) require treatment independent of the
     pain
     (C) are rare among the elderly
     (D) are always reactive or secondary to the
     pain
     (E) require thorough assessment by a psychopharmacologist

Answer 1

833. (B) Reviews clearly suggest that affective symptoms
     require treatment independent of the
     patient’s pain, either through pharmacotherapy,
     behavioral therapies, or both. Depression is
     common in chronic pain populations, with rates
     that exceed 50% within some populations.
     Unfortunately, physician adherence with respect
     to depression screening is poor. Risk of suicide
     can be significant with an untreated depression,
     and the elderly often fail to undergo adequate
     assessment. While consultation by a psychopharmacologist
     is desirable, many primary
     care physicians and other subspecialists elect to
     pharmacologically manage depression.

Question 2

834. Which of the following include risk factors for
completed suicide?
(A) Age
(B) Substance abuse
(C) History of prior suicide attempts
(D) Chronic medical conditions
(E) All of the above

Answer 2

834. (E) While the ability to predict suicide is poor
     even among mental-health clinicians, the above
     illustrate commonly accepted risk facts. The
     presence of past suicide attempts is another predictor.
     The elderly, males, and those with chronic
     medical conditions are at great risk for suicide
     completion.

Question 3

835. Tricyclic antidepressants
     (A) have been shown to assist with reducing
     neuropathic pain
     (B) have been shown to assist with chronic
     headache
     (C) should be closely monitored in depressed
     patients because of suicide risk and possible
     lethality of an overdose
     (D) have been infrequently used in the treatment
     of major depression
     (E) A, B, and C

Answer 3

835. (E) While commonly used in pain practice,
     dosing of tricyclic antidepressants is rarely sufficient
     to cover comorbid major affective symptoms.
     Other commonly used antidepressant
     agents or proper dosing should be considered
     when significant affective symptoms are present,
     with close monitoring given the risk factors
     associated with an overdose.

Question 4

836. Substance abuse risk assessment
     (A) is required as a minimum standard of
     care with chronic pain
     (B) is poorly conducted by most physicians
     (C) can reduce medico-legal risk when
     chronic opioid therapy is being considered
     (D) can be improved by use of brief, standardized
     screening questionnaires
     (E) all of the above

Answer 4

836. (E) Substance abuse risk screening is generally
     considered required in all standard initial medical
     assessments, while physician adherence is
     poor. Serious substance abuse history and current
     substance abuse predicts to poor outcome
     with a range of medical treatments. Chronic pain patients may be at high risk for substance
     use disorders, and medico-legal risks may be
     present for physicians who fail to conduct
     adequate screening and refer the patient for
     treatment.

Question 5

837. Patient self-report data is
(A) highly reliable when a spouse is present
in the interview
(B) always subject to bias
(C) often unreliable with assessment of
substance abuse, unless toxic screening
is used
(D) more reliable when an anxiety disorder
is present
(E) all of the above

Answer 5

837. (B) The field has an inherent handicap because
     of the subjective nature of pain. Bias is always
     present with self-report, and reliability of pain
     ratings is poor. Presence of a significant other
     can greatly assist with validation of patient selfreport,
     while the bias remains. Substance abuse
     assessment is necessary, self-report remains the
     only practical strategy, and toxic screening does
     not necessarily improve the veracity of the
     patient’s report. Comorbid psychologic symptoms
     further compromise self-report. While
     assessment of pain level is necessary, additional
     assessment of other outcome variables remains
     important, that is, functional activities, return
     to work, medication adherence.

Question 6

838. Spouse “oversolicitous” behavior
     (A) can be assessed with the Minnesota
     Multiphasic Personality Inventory-2
     (MMPI-2)
     (B) can contribute to poor treatment outcome
     (C) controls most of the variance in predicting
     disability and substance abuse
     (D) is generally a reflection of positive social
     support, and should be reinforced
     (E) all of the above

Answer 6

838. (B) The construct “oversolicitiousness” has
     been studied since the mid 1980s with the work
     of Andrew Block. The oversolicitious spouse
     is considered overly attentive to pain and disability
     behavior, potentially influencing the
     patient’s report of pain and reinforcing pain
     behaviors. Several standardized assessment
     instruments address degree of spouse oversolicitiousness,
     such as the Multidimensional
     Pain Inventory. Therapy programs can incorporate
     treatments designed to modify spouse
     behavior and thereby improve the patient’s
     treatment outcome, while other factors may
     control more of the variance with respect to
     overall pain level, disability, or other comorbid
     psychiatric symptoms.

Question 7

839. Somatization disorder
     (A) commonly develops in the elderly, as a
     result of poor communication with
     health care providers
     (B) precludes the presence of an organic
     disease or disorder
     (C) develops in adolescence, with symptoms
     disappearing by the age of 35 years
     (D) implies the patient is intentionally
     “making up” symptoms
     (E) complicates the pain physician’s ability
     to evaluate effectiveness of the treatment

Answer 7

839. (E)Adiagnosis of somatization disorder is often
     missed in subspecialty practices. While the
     patient may present with a discrete pain complaint,
     comprehensive assessment and adequate
     record review may reveal a history of multiple
     somatic symptoms. The Diagnostic and Statistical
     Manual of Mental Disorders (Fourth Edition, Text
     Revision) (DSM-IV-TR) outlines criteria that
     include onset prior to age 30 years, and multiple
     unexplained symptoms persist with varying
     severity over many years. Patients are not “malingering”
     or feigning symptoms with this diagnosis.
     Comorbid disorders such as posttraumatic
     stress disorder and history of emotional trauma
     may be present. Patients may undergo questionable
     interventional or surgical procedures, and
     develop secondary iatrogenic problems. Other
     comorbid medical diagnoses may be missed, and
     ongoing assessment is compromised as a result of
     the patients impaired self-report. Patient resistance
     to psychologic intervention is great and outcomes
     for those who agree to treatment are
     generally poor. Coordinated management of the
     somatization disorder patient through primary
     care often is the mainstay, while pain specialists
     may assist with close communication among
     providers.

Question 8

840. Anxiety symptoms are common among most
     patients with chronic conditions, and
     (A) structured anxiety questionnaires can
     replace time-consuming interview questions,
     providing they have sufficient
     reliability and validity
     (B) anxiety symptoms with acute pain often
     abate after adequate treatment of the pain
     (C) posttraumatic stress disorder is common
     when a history of domestic abuse is
     present
     (D) anxiety symptoms rarely abate after
     adequate treatment of pain
     (E) both B and C

Answer 8

840. (E) Anxiety symptoms are common with all
     chronic pain and many acute pain conditions,
     while few pain patients meet psychiatric diagnostic
     criteria for an anxiety disorder, for example,
     posttraumatic stress disorder. In many
     cases, anxiety symptoms may abate when
     proper pain treatment occurs, either in acute or
     chronic pain. Some conditions do predict to a
     high likelihood of anxiety disorder, such as history
     of domestic abuse. Anxiety may persist in
     other chronic pain conditions and combined
     behavioral and pharmacologic treatments are
     often required. While many pain questionnaires
     address anxiety symptoms, screening questionnaires
     do not absolve the clinician from conducting
     an adequate interview assessment.

Question 9

841. With a work related spine injury, pain and disability
are most dependent upon
(A) the level of the disc herniation
(B) the employee’s appraisal of his work
setting
(C) the patient’s level of depression
(D) the adequacy of the patient’s pharmacotherapy
regimen
(E) all of the above

Answer 9

841. (B) While there are multiple factors associated
     with pain and disability and individual differences
     must be addressed, most investigations
     point toward the patient’s appraisal of the
     work setting as a major factor influencing pain and disability, regardless of injury severity.
     Psychosocial factors associated with coping
     within a difficult work environment may be
     moderating factor. Investigators have not suggested
     malingering or feigning of pain as an
     explanation of these results.

Question 10

842. In general, a successful return to work with
     back pain is more likely if
     (A) the patient is placed on light duty
     (B) the return to work is rapid, ideally
     within 12 months of the injury
     (C) ergonomic job modifications are made
     at the work-site
     (D) time-release versus short-acting analgesics
     are employed
     (E) psychological job counseling is instituted
     shortly after the injury

Answer 10

842. (B) Timing appears to be a major factor with
     respect to successful return to work, with a rapid
     drop off in success after the 12-month mark.
     Despite widespread use, “light duty” strategies
     have shown mixed results, and greater success
     has been shown where no restrictions were proposed.
     The role of pharmacotherapy and return
     to work hasn’t been adequately studied. While
     there may be a role for early psychologic counseling
     in some cases, data with respect to effect
     of counseling within this narrow time period
     are limited. Similarly, ergonomic modifications
     have shown limited effect, particularly in cases
     where chronic pain is present. When a patient’s
     condition becomes more chronic, highly structured
     functional restoration rehabilitation
     approaches have shown the most promise with
     respect to return to work.

Question 11

843. Biofeedback assisted relaxation has been
shown to be effective in reducing frequency,
duration, and severity of pain with
(A) myofascial pain conditions and
migraine
(B) cluster headache
(C) trigeminal neuralgia
(D) postherpetic neuralgia
(E) all of the above

Answer 11

843. (A) EMG and thermal biofeedback involve the
     surface monitoring of physiological responses,
     with ongoing graphic visual or audio feedback to
     the patient. Relaxation training or cognitive techniques
     are employed to master control over the
     physiologic response, and additional practice
     techniques assist the patient to generalize the
     relaxation response to other settings. Studies suggest
     that adjunctive use of the biofeedback equipment
     offers benefit to some patients, and may be
     more effective with particular pain conditions.
     Positive outcomes have been demonstrated with
     migraine and various pain conditions considered
     as myofascial. Results with cluster headache
     are less promising, as are results with other specific
     neuropathic pain conditions. Nonetheless, a
     positive general relaxation effect has been shown
     with multiple pain conditions.

Question 12

844. In general, compliance rates or “adherence”
with pharmacotherapy recommendations is
(A) 70% if a chronic medical condition is
present
(B) dependent upon the severity of the
chronic condition
(C) greater with elderly patients
(D) dependent on the patient’s intelligence
level
(E) improved when the pain clinician is
“emphatic,” and readily accepts the
patient’s report of pain severity

Answer 12

844. (B) Poor adherence is common with any chronic
     medical condition and worse when comorbid
     psychiatric disorders are presence. Adherence is
     defined as the extent to which the patient’s behavior
     coincides with medical recommendations. The term “compliance” has fallen in disfavor, as
     the term “adherence” assumes a more nonjudgmental
     assessment of the patient’s behavior.
     Adherence is unrelated to age, sex, race, or intelligence.
     Notwithstanding extensive research on
     improving adherence, effects of various interventions
     have been modest with respect to changing
     difficult patient behavior. Within the field of
     pain medicine, particular attention has been pain
     to adherence when chronic opioid therapy is considered.
     Screening for risk factors and urine toxicology
     combined with structured treatment may
     result in improved adherence, while studies are
     still lacking. Adherence may be improved by simplified
     dosing schedules, increased frequency of
     office visits, reinforcing the importance of adherence
     when counseling the patient, and enlisting
     family members in the treatment plan. Where a
     language or cultural barrier is present, adherence
     may improve by enlisting skilled interpreters and
     clinicians who have an in-depth understanding of
     the particular cultural issues.

Question 13

845. Factors suggestive of a possible problematic
     course with chronic opioid therapy include
     (A) tobacco use
     (B) history of inpatient detoxification
     (C) a high score on a standardized chronic
     opioid therapy–screening instrument
     (D) comorbid psychiatric diagnosis such as
     posttraumatic stress disorder
     (E) all of the above

Answer 13

845. (E) Screening for chronic opioid therapy has
     received increasing attention, as risk factors
     have received closer scrutiny and outcomes
     have been poor with some patients. Among
     others, all of the above choices have been predictors
     of poor outcome. Several screening
     questionnaires have been developed with adequate
     reliability and validity, and these may
     assist the clinician in formulating an effective
     treatment plan. Examples include the SOAPP
     (Screener and Opioid Assessment for Patients
     with Pain) and DIRE (Diagnosis, Intractability,
     Risk and Efficacy Score) rating scale. Tobacco
     use, history of detoxification, and various
     comorbid psychiatric diagnoses may predict
     to a problematic course. Many State Medical
     Board Model Pain Policies suggest that special
     attention be paid to these at-risk patients when
     chronic opioid therapy is considered.

Question 14

846. Adiagnosis of posttraumatic stress disorder is
     (A) uncommon among pain patients who
     have domestic violence histories
     (B) a risk factor in the development of a
     treatment-resistant chronic pain
     disorder
     (C) not predictive of poor adherence when
     treating chronic pain conditions
     (D) present in 70% of motor vehicle accidents
     who report neck pain after the
     first 12 months
     (E) generally resolved within the first few
     weeks of a major trauma, provided that
     the patient has adequate treatment of
     acute pain

Answer 14

846. (B) Posttraumatic stress disorder (DSM-IV-TR)
     is classified as an anxiety disorder and often
     co-occurs with other psychiatric disorders.
     Posttraumatic stress disorder has been considered
     a risk factor with respect to development
     of treatment resistant chronic pain disorders.
     Patients may have frequent or recurrent periods of hyperarousal, and chronic symptoms may
     suggest a problematic course for pain treatment.
     While present in few motor vehicle accident
     victims after 1 year, other trauma precipitants
     such as early physical/sexual abuse or extensive
     domestic violence often result in chronic
     symptoms and a more complicated treatment
     course. Comanagement with a mental-health
     specialist is always recommended.

Question 15

847. Patient pain ratings
(A) should be documented by the clinician
during each visit
(B) are not particularly reliable
(C) are poor predictors of disability
(D) should be supplemented by other measures
when chronic pain is present
(E) all of the above

Answer 15

847. (E) Despite issues of reliability and the subjective
     nature of pain ratings, pain clinicians are
     required to record the patient’s self-report, that
     is, the “fifth vital sign.” Reliability is improved
     with increased frequency of ratings, and special
     populations may require a modification and/
     or improved description of the rating scale.
     Clinical relevance of ratings with chronic pain
     may be less than acute pain, as multiple problem
     areas are often present. Other adjunct
     assessments could include standardized measures
     for quality of life. The pain clinician can
     also supplement pain ratings through documentation
     of other objective indicators, for
     example, the patient may state that “I can now
     walk 20 minutes…I returned to work…I’m using
     medication as prescribed now….”

Question 16

848. Commonly used quality of life measures
include
(A) Beck Depression Inventory and CES-D
depression screening questionnaire
(B) Short Form-36 (SF-36) and the Sickness
Impact Profile (SIP)
(C) Brief Pain Inventory
(D) Headache Disability Index
(E) MMPI-2

Answer 16

848. (B) While the other symptom-specific instruments
     are commonly used in pain, clinic settings,
     the SF-36 and SIP illustrate an example
     standardized instruments that are becoming
     increasingly important in health care settings as
     efforts are made to evaluate overall outcome.

Question 17

849. Psychological screening for spinal column
     stimulation should
     (A) weigh the patient’s realistic and unrealistic
     expectations for outcome
     (B) exclude patients with a major depression,
     given a probable poor prognosis
     (C) underscore the patient’s likelihood for
     improved work capacity after successful
     implantation
     (D) address possible malingering by the use
     of standardized psychologic testing
     (E) all of the above

Answer 17

849. (A) There do appear to be predictors of a problematic
     course with spinal column stimulation,
     while these tend to be the same predictors that
     suggest poor outcome with most pain treatments.
     Nonetheless, predictive validity studies
     have been few. Screening by a psychologist may
     help to better delineate possible predictors, and
     formal screening is often required by third party
     carriers. Realistic patient expectations may be
     particularly important with neurostimulation
     procedures. For example, spinal column stimulation
     may offer the patient pain relief, while
     structured rehabilitation approaches tend to
     show better outcome when goals such as return
     to work or improved function are targeted. Patients with particular psychiatric conditions
     do not necessarily have a poor outcome if their
     symptoms can be readily treated, for example,
     major depression. Conversely, a diagnosis of
     somatization disorder or substance use disorder
     may predict a more difficult course of treatment.
     In some cases, problem areas can be
     identified and treated prior to embarking on
     neurostimulation, and outcome may be better.

Question 18

850. There is a greater likelihood of improved function
     and return to work when
     (A) passive rehabilitation approaches are
     paired with biobehavioral approaches
     (B) interventional approaches are paired
     with cognitive therapies
     (C) active rehabilitation approaches are
     combined with cognitive therapies
     (D) complimentary medicine approaches are
     combined with cognitive therapies.
     (E) opioid therapy is combined with a light
     duty return-to-work schedule.

Answer 18

850. (C) “Passive” rehabilitation approaches are
     considered to be less effective than “active”
     interventions when function or return to work
     are considered. Active approaches involving
     quota-based exercise may help the patient to
     reduce fear of pain and activity. Passive
     approaches sometimes rely on the patient being
     less involved, and may depend upon the clinician
     to provide the relief. Many active
     approaches have been coupled with cognitive
     therapies, resulting in a greater effect. Fewer
     definitive studies have addressed results of
     return to work with interventional procedures,
     opioid treatments, or complimentary therapies.
     While most investigations have been conducted
     with chronic back and neck populations,
     fibromyalgia and other conditions tend to
     show better functional improvement with more
     active versus passive rehabilitation approaches.

Question 19

851. In part, factors associated with the placebo
     effect include
     (A) patient and clinician expectations
     (B) past learning and conditioning
     (C) neurotransmitter responses
     (D) credibility of the treatment intervention
     (E) all of the above

Answer 19

851. (E) Research on the placebo and nocebo effect is
     well-established in the pain field. A placebo
     effect can be as high as 100%, depending upon
     multiple variables. It’s generally acknowledged
     that interventional treatments may have greater
     placebo effect than oral medications, and surgical
     approaches potentially have the greatest
     effect. While “noise” associated with reference to
     the placebo effect if often addressed in clinical
     trials, efforts to understand and “harness” the
     role placebo in clinical care has received growing
     attention. Investigations have revealed that
     clinicians tend to overestimate the impact of
     their treatments and underestimate the power of
     placebo or other nonspecific factors.

Question 20

852. A patient with chronic daily headache and
     myofascial neck pain improves after a series
     of trigger point injections. The effect could be
     attributed to
     (A) the treatment intervention
     (B) the natural course of the illness or
     “regression to the mean”
     (C) placebo effect associated with the injections
     (D) other concurrent treatment changes that
     may have occured, for example, patient
     terminated a prophylactic treatment in
     anticipation of the injection series
     (E) all of the above

Answer 20

852. (E) Determining outcome based upon any particular
     treatment remains difficult with chronic pain
     conditions, and the effect on nonspecific or other
     treatment variables always must be considered.

Question 21

853. Pain support groups and online support organizations
     (A) may reinforce the patient’s somatic
     overconcern and promote disability
     behavior
     (B) provide a valuable resource of information
     with chronic pain conditions, and
     help to minimize distress and tendency
     to feel isolated
     (C) may provide the pain patient with critical
     evaluations of his/her health care
     provider
     (D) are not a replacement for psychologic or
     psychiatric treatments
     (E) all of the above

Answer 21

853. (E) Studies of support organizations and volunteering
     suggest that these approaches may
     be a valuable resource for the pain patient,
     while the pain physician should use caution
     with respect to referral. Some organizations
     such as the American Chronic Pain Association
     provide admirable support and information,
     while fringe advocacy groups may increase the
     patient’s distress and divert the patient from
     the most appropriate treatments.

Question 22

854. Historically, the traditional operant-conditioning–
     pain-rehabilitation programs
     (A) expected the patient to increase activity
     levels until pain became severe
     (B) measured level of pain as an integral
     component of assessment
     (C) regarded as-needed analgesic consumption
     as a “pain behavior”
     (D) established objective functional and
     recreational goals after the pain was
     adequately controlled
     (E) all of the above

Answer 22

854. (C) One of the first and most well known operant
     pain rehabilitation programs for chronic
     noncancer pain was established in Seattle
     Washington in the late 1970s under the guidance
     of Drs Wilbert Fordyce and John Loesser.
     On an intensive inpatient basis, patients were
     taught to increase function despite pain, recreational
     and other “well behaviors” were
     socially reinforced, and “pain behaviors” were
     ignored. Examples of pain behaviors included
     grimacing, pill consumption, or complaints of
     pain. Objective program goals were established
     prior to starting treatment. Functional outcomes
     were positive, and programs with varying
     levels of operant focus were developed
     throughout the country. Economic pressure
     forced programs to convert to outpatient services,
     and operant oriented “functional restoration
     programs” thrived into the late 1980s.
     Additional economic pressures ensued and
     most programs closed. Currently, there appears
     to be a resurgence of programs with this focus,
     given continued perceived need.

Question 23

855. The Minnesota Multiphasic Personality Inventory
     (MMPI-2)
     (A) is a brief, “clinician-friendly,” self-report
     questionnaire that does not require
     interpretation by a clinical psychologist
     (B) has rarely been challenged with respect
     to its utility in chronic pain settings,
     with most pain psychologists accepting
     the MMPI-2 as the testing instrument of
     choice
     (C) is a 566 item true/false self-report
     instrument used to assist with the
     assessment of overall psychopathology
     (D) has limited utility in clinical settings,
     primarily because of the lack of chronic
     pain normative data
     (E) can assess whether a patient is malingering
     with respect to report of pain level

Answer 23

855. (C) The MMPI-2 has been widely administered
     in pain clinic settings as a general measure of
     psychopathology, while its use has declined over
     the last 15 years. Results provide an overall
     measure of psychopathology, while some clinicians
     with extensive training in the MMPI-2
     argue that specific psychologic deficits can be
     ascertained from the results. The focus on psychopathology,
     its length (500+ items), and training
     requirements for interpretation have resulted
     in a reduction in its use. Other psychologic tests
     specifically developed for chronic pain have seen
     increasing use, while a long history of predictive
     validity studies suggests that the MMPI-2 will
     likely continue to be used in pain clinic settings.

Question 24

856. Which of the following are commonly employed
     cognitive behavioral techniques with pain conditions?
     (A) Cognitive restructuring, problem solving,
     and dialectical behavior therapy
     (B) Progressive muscle relaxation, autogenic
     training, and psychoanalytic
     psychotherapy
     (C) Contingency management, stimulus
     generalization, and operant conditioning
     (D) Surface electromyographic (EMG)
     biofeedback, thermal biofeedback, and
     muscle reeducation
     (E) All of the above

Answer 24

856. (A) Cognitive therapies include the use of specific
     techniques targeted toward the patient’s
     perception of pain or disability. Maladaptive
     thought patterns are altered or “restructured.”
     Dialectical behavior therapy offers a similar,
     highly structured approach aimed at systematically
     modifying thoughts, often directed at
     disordered cognitions present with chronic
     depression or posttraumatic stress disorder.
     While most behavioral specialists agree that
     relaxation training, biofeedback, and operant
     strategies (contingency management, stimulus
     generalization, operant conditioning) have a
     large cognitive therapy component, these treatments
     generally are considered separate from
     standard cognitive approaches.

Question 25

857. Apatient returns to work despite a fear of reinjury,
     and remains in the work setting until the
     fear gradually subsides. From a learning theory
     standpoint, this is considered
     (A) punishment
     (B) in vivo exposure
     (C) negative reinforcement
     (D) intermittent reinforcement
     (E) systematic desensitization

Answer 25

857. (B) In vivo exposure requires the patient to
     remain in the feared setting until the anxiety
     subsides. If the patient leaves at the height of
     the anxiety (or during the most severe pain),
     the patient may increase the severity of the
     phobia. Studies support a rapid return to work
     for work-injured patients in an effort to provide
     them with an in vivo exposure and reduce fear
     of activity. However, it’s important that the
     patient have a “success,” and remain in the
     work setting until the anxiety subsides. Ideally,
     the patient discovers that engaging in work
     tasks does not result in a reinjury. The worker
     may have intermittent exacerbations of pain,
     but also learns that pain subsides and does not
     result in greater physical “harm.” The construct
     of punishment reduces behavior, while negative
     reinforcement increases behavior, for example,
     the patient terminates the aversive work
     setting by leaving. Systematic desensitization is
     a treatment method that generally requires to a
     graded exposure using guided imagery within
     a therapy setting. Work-simulation or workhardening
     programs employ a similar principle
     by gradually reducing the patient’s fear of
     work activity or increased pain. After achieving
     some level of relaxation and confidence, the
     clinician then introduces the patient to the in
     vivo work setting

Question 26

858. Hypnosis is often used to
(A) reduce acute pain and relax the patient
(B) improve adherence
(C) treat posttraumatic stress disorder
(D) treat cluster headache
(E) both A and D

Answer 26

858. (A) Hypnotic analgesia has a long history as an
     adjunctive treatment for pain, with formal procedures
     for hypnosis dating back several hundred years. Some argue that the effects are similar to
     other standardized relaxation procedures, and
     self-hypnosis resembles many relaxation techniques.
     Positive effects have been shown with
     acute and chronic pain conditions. Studies
     addressing patient adherence suggest a role for
     multiple complex variables, and hypnosis has
     not been proposed as an important intervention
     for adherence. Other behavioral and pharmacologic
     strategies have shown much greater
     effect with conditions such as posttraumatic
     stress disorder or cluster headache.

Question 27

859. Apatient is being considered for an implantable
     opioid pump. Which of the following can be
     considered a reasonable outcome, based upon
     current evidence-based reviews?
     (A) Reduced side effects from oral opioid
     therapy
     (B) Return to work and increase in recreational
     activity
     (C) Reduced pain and depression
     (D) Improved aerobic capacity and reduced
     side effects from opioids
     (E) None of the above

Answer 27

859. (A) While implantable pumps have demonstrated
     effect with respect to reduced pain and
     reduced side effects from oral opioid therapy,
     objective gains with respect to improved function
     or change in emotional status are lacking.
     Psychologic techniques have been successfully
     employed to better prepare patients for
     implantable devices, most notably specific cognitive
     techniques.

Question 28

860. “Mind-body” and structured “stressmanagement”
     programs often employ
     (A) short-term, time-limited treatment
     techniques
     (B) monitoring of stressors and precipitants
     of pain
     (C) cognitive therapy to reduce perception
     of pain and control over all symptoms
     (D) relaxation training
     (E) all of the above

Answer 28

860. (E) Mind-body and structured stress-management
     groups have been integrated into overall
     patient care, with promising results. These techniques
     may buttress rather than replace individual
     therapeutic approaches, especially in
     cases where chronic disability and more significant
     comorbid psychiatric disorders are present.

Question 29

861. Cognitive behavioral treatments with pain in
     children might typically include all of the following
     EXCEPT
     (A) enlisting parents to assess mediating
     stressors and reinforce positive coping
     skills
     (B) structured play therapy
     (C) relaxation training with possible adjunctive
     use of biofeedback
     (D) rehearsal of positive cognitions
     (E) efforts to return the child to school in
     order to minimize school phobia and
     disability behavior

Answer 29

861. (B) Cognitive behavioral treatments for children
     with acute and chronic pain are typically short in
     duration and goal oriented. Pain and painrelated
     distress may be targeted, and functional
     activities may be reinforced. Involvement of the
     family or school can optimize outcome. While
     traditional play therapy approaches are common
     in child-treatment settings, the structure and
     short-term nature of cognitive therapy interventions
     would unlikely include this approach.

Question 30

862. Functional sleep disorders are common with
     chronic pain conditions, with as many as 80%
     of pain patients reporting problems with sleep.
     Behavioral approaches have consistently been
     shown to be superior to pharmacotherapy
     approaches. Which of the following is included
     in a behavioral approach to functional sleep
     disorder?
     (A) Instruction in proper sleep hygiene and
     use of stimulus-control techniques
     (B) Relaxation training and cognitive interventions
     (C) Self-monitoring of sleep, with particular
     focus on sleep habits and anxiety symptoms
     (D) Addressing common precipitants of
     poor sleep such as depression, inappropriate
     use of pharmacologic sleep aids,
     and/or substance use
     (E) All of the above

Answer 30

862. (E) Sleep disorders are exceedingly common
     among patients with chronic pain conditions,
     with prescription and over-the-counter sleep aids
     often providing limited benefit. Recent investigations
     have suggested that myofascial pain
     complaints may be precipitated or worsened by
     poor sleep, and disrupted sleep is well established
     as a precipitant of migraine headache.

Question 31

863. Temporomandibular disorders have been most
     effectively treated by a combination of
     (A) interventional and biobehavioral techniques
     (B) biobehavioral and oral/dental/occlusal
     appliance therapy
     (C) physical therapy and biobehavioral
     techniques
     (D) low-dose chronic opioid therapy and
     thermal biofeedback
     (E) none of the above

Answer 31

863. (B) Defining temporomandibular disorders
     remain a problem, as with many chronic pain
     conditions. However, the role of myofascial
     factors is generally accepted, and recommendations
     from evidence-based reviews have consistently
     supported a role for cognitive and
     relaxation approaches. Dentists with an orofacial
     pain subspeciality also often manage these
     patients, and studies have shown the best effect
     with combined therapies. Opioid therapy,
     physical therapy, and various interventional
     procedures have been less well-studied with
     chronic temporomandibular disorders.

Question 32

864. A patient presents with symptoms of chronic
     hand-arm pain, possibly neuropathic in origin,
     as well as a diagnosis of fibromyalgia with
     associated disability and depression. Which of
     the following is best treatment for this patient?
     (A) Referral to cognitive therapy
     (B) Multidisciplinary treatment, where
     behavioral interventions are integrated
     into the patient’s care
     (C) Interventional treatments, where appropriate,
     while concurrently referring the
     patient to a psychologist with a specialty
     in pain management
     (D) Pharmacotherapy as a first-line treatment,
     with appropriate psychologic screening
     for risk factors if opioids are considered
     (E) Treatment modalities that directly
     address the patient’s presenting diagnosis,
     for example, a diagnosis of complex
     regional pain syndrome may require
     interventional procedures and/or neurostimulation,
     referral for behavioral
     treatment, and eventual referral to
     physical therapy

Answer 32

.864. (B) When disability and depression are present
with multiple chronic pain conditions, the minimum
standard of care requires a multidisciplinary
effort. Sequential efforts that start with
pharmacotherapy or interventional treatments
may extend the patient’s period of disability and
distress, and cross-discipline multidisciplinary
coordination remains the standard of care.
However, access to some specialty care may limit
the pain physician’s options, as psychological or
rehabilitation services may be denied by an
insurance carrier. Nonetheless, the data continue
to support a multidisciplinary approach from
the onset of the patient’s care.

Question 33

865. Addiction can co-occur with chronic pain disorders.
     If chronic pain and an addictive disorder
     co-occur, the patient
     (A) can be effectively managed when the clinician
     primarily relies on interventional
     treatments
     (B) requires referral for comanagement by
     an addiction specialist
     (C) may show a decrease in addictive
     behavior, as many patients engage in
     addictive behavior because of inadequate
     treatment of pain
     (D) requires an inpatient detoxification from
     the addictive substances prior to pain
     treatment
     (E) should never be treated with chronic
     opioid therapy

Answer 33

865. (B) The AAPM (American Academy of Pain
     Medicine)/APS (American Pain Society)/ASAM
     (American Society of Addiction Medicine) joint
     statement states that “addiction is a primary,
     chronic, neurobiological disease, with genetic,
     psychosocial, and environmental factors influencing
     its development and manifestations. It is
     characterized by behaviors that include one or
     more of the following: impaired control over
     drug use, compulsive use, continued use despite
     harm, and craving.” The IASP (International
     Association for the Study of Pain) Core
     Curriculum further asserts that “adequate pain
     treatment will be difficult or may fail without
     concurrent treatment of addiction.” Given the
     complexity of addictive disorders, comanagement
     is necessary. In many cases, addictive
     behavior can be managed on an outpatient basis.
     Opioid therapy is not an absolute contraindication
     in cases where the patient displays additive
     behavior, while care should be taken by close comanagement of the patient by other relevant
     specialists.

Question 34

866. In population-based studies, women suffering
     from pain
     (A) typically do not report more severe and
     frequent pain than men
     (B) may be at greater risk for specific pain
     disorders, for example, fibromyalgia,
     temporomandibular disorders, and
     migraine
     (C) have been shown to be at greater risk
     because of endogenous and exogenous
     sex hormone changes
     (D) may be subject to multiple psychosocial
     and cultural influences that impact on
     report of pain
     (E) B, C, and D

Answer 34

866. (E) Sex differences with respect to pain are well
     established, and recent animal studies appear to
     buttress these results. Women may report more
     frequent and severe pain than men, and hormonal
     factors, in part, may play a role. Psychosocial differences
     also appear to play a role. Conversely,
     women also have shown a more robust treatment
     effect than men with rehabilitation and multidisciplinary
     interventions.

Question 35

867. Aperson’s degree of belief that he/she can successfully
manage aspects of their pain, including
their pain level, is termed
(A) catastrophizing
(B) self-esteem
(C) cognitive coping skill
(D) self-efficacy
(E) locus of control

Answer 35

867. (D) While all of the above constructs are addressed
     in cognitive treatment, self-efficacy is the defined
     construct. Self-efficacy is often associated with
     the early work of Albert Bandura, and researchers
     in the pain field have developed relevant assessment
     instruments. Self-efficacy is addressed clinically
     when the patient is trained to internalize the
     belief that he/she is capable and has the skills to
     managing exacerbations in pain, coordinating
     his/her medical care, or improve on some specific
     functional task.

Question 36

868. The construct of operant conditioning would
apply to the following patient vignette:
(A) A worker has an acute back injury while
lifting an object at work, experiences
immediate pain and associated anxiety,
and thereafter develops an unrealistic
fear of any future lifting behavior
(B) A patient uses a short-acting opioid
after an exacerbation of pain. He learns
to take his pill when his pain reaches a
certain level. His pill-taking behavior is
initially reinforced by the effect of the
analgesic or other nonspecific factors
that contributed to his pain reduction
(C) A patient in physical therapy engages in
her exercise “until I can’t stand the
pain,” then discontinues the exercise,
seeks bedrest, and rapidly feels better.
She learns that escaping from physical
therapy and lying down reduces her
pain, and continues this behavior
(D) A patient becomes markedly anxious
during the preparation for an interventional
procedure, and the procedure is
terminated prematurely owing to her
anxiety. Upon returning to the pain clinic,
the patient leaves the procedure room as
her anxiety escalates. She has become
phobic of interventional procedures
(E) Both B and C

Answer 36

868. (E) While all of the answer choices could
     include components of operant and classical
     (respondent) conditioning, choices (B) and (C)
     address the issue of reinforcement. In contrast,
     “classical” conditioning involves the pairing
     of a neutral (lifting, preparation for a procedure)
     with an immediate noxious (pain, anxiety)
     stimulus or pleasant stimulus. Often after
     one or repeated trials, reintroducing the “neutral”
     stimulus (a nerve block, a lifting episode)
     produces the unwanted response, that is, anxiety
     as outlined in a cases above. With respect
     to operant conditioning, a behavior is reinforced
     and thereby increases in frequency.

Question 37

869. There is empirical evidence to support
     (A) the construct of a “pain prone personality”
     (B) the concept that chronic pain is “masked
     depression”
     (C) malingering as being rare, less than 1%
     with work injury-related chronic pain
     conditions
     (D) the assumption that psychologic trauma
     may increase the likelihood of developing
     a treatment-resistant chronic pain
     disorder
     (E) all of the above

Answer 37

869. (D) The construct of a “pain prone personality”
     has largely been discredited, as has the construct
     of pain as a “masked depression.”
     However, multiple psychosocial factors appear
     to be predictors of developing chronic pain disorders,
     while they are not necessarily causes.
     Rates of malingering, or consciously lying
     about disability and pain, appear to vary. Pain
     physicians are poor at assessing malingering,
     while most investigations agree that rates are higher in any circumstances where active
     adversarial/litigation is present. It is most
     important to note that malingering can occur
     when a legitimate medical or psychiatric condition
     is also present.

Question 38

870. A patient arrives at the pain center with persistent
     facial pain, secondary to a fall 6 months
     earlier. She has a history of other pain complaints,
     and reports that she follows with a
     counselor for “stress.” When evaluating the patient, the diagnostic interview content should
     include psychosocial questions that address
     (A) depression and suicidal ideation
     (B) substance use
     (C) risk of domestic violence
     (D) all of the above
     (E) none of the above, while the patient
     should grant permission to the pain
     physician to speak with her counselor

Answer 38

870. (D) The involvement of a mental-health specialist
     in the patient’s care does not absolve the
     pain clinician of covering standard psychosocial
     interview questions within the assessment
     interview. State regulations also may require
     that the clinician address risk factors associated
     with domestic violence, and the above
     case would appear to suggest the presence of
     this risk. The pain clinician also must be aware
     or have access to resources for appropriate
     referral in cases where patients may be at risk.

Question 39

871. Patients with cognitive impairments and pain
     (A) may require administration of specific
     assessment tools relevant for their
     impairment, as standard pain assessment
     may be inadequate
     (B) may be at risk for undertreatment of
     pain because of communication difficulties
     with the pain clinician
     (C) are at higher risk for accidental injury
     (D) do not necessarily have an intellectual
     disability
     (E) all of the above

Answer 39

871. (E) There are a range of conditions that require
     special attention by the pain clinician, for example,
     patients with dementia, head injuries,
     stroke, memory disorders, or developmental
     disabilities. These disorders can influence the
     patient’s social and psychologic presentation,
     and their ability to communicate level of pain
     and impairment. Comanagement of similar
     patients with subspecialists in neurology,
     neuropsychology, occupational therapy, and
     related disciplines may maximize positive
     outcome.

Question 40

872. Adjunctive psychologic treatments for cancer
pain might include
(A) cognitive therapies to improve patient’s
control over the medical treatment
sequence
(B) autogenic relaxation training
(C) hypnosis
(D) brief family therapy
(E) all of the above

Answer 40

872. (E) While acute and cancer pain conditions may
     require a modification of techniques, behaviormanagement
     strategies are often integrated into
     multidisciplinary treatment team management.