Chapter 6 Psychological Evaluation and Testing Flashcards
KEY POINTS 1. Psychological evaluations for pain and disability typically include psychological testing and an interview. 2. Key domains for assessment include pain-related disability, negative affect, pain-related cognitions, coping strategies, psychopathology, and substance use. 3. Multidimensional instruments offer the potential of assessing selected key domains as well as social factors. 4. When interventional pain therapy is being considered, it is advisable to obtain a specialized psyc
Key components of a psychological evaluation for chronic pain
The clinical interview including behavioral observation and the use of standardized
testing instruments
The clinical interview addresses multiple
aspects of what?
Individual’s cognitive, medical, educational,
social, employment, and psychiatric history
Why is the clinical interview the cornerstone of the psychological
evaluation?
due to the subjective nature of the pain
experience and the relatively limited set of standardized psychological measures that have normative data for chronic pain patients
What is the important objective of the interview ?
to identify any psychiatric conditions that might exacerbate pain or complicate treatment, such as psychosis, substance dependence, or a personality disorder
What information does observation of pain behaviors provide?
the person’s overall pain experience, coping, and the extent
of pain-related disability. Pain behaviors—such as ability to sit through the interview, verbal complaints and other
sounds (e.g., grunting and moaning), facial expressions (e.g., grimacing, wincing), and bodily gestures (e.g., bracing when changing positions, moving in a distorted fashion)— are noted during the interview.
Brief Pain Inventory (BPI)
was developed to measure pain severity
and pain-related interference in patients diagnosed with
cancer, osteoarthritis,and neuropathic pain.
an 11-point numeric rating
scale (where 0=no interference and 10= interferes completely) to assess pain-related interference.
Seven Areas of Brief Pain Inventory (BPI)
general activity, mood, walking ability, normal work including outside the home and housework, relations with other people, enjoyment of life, and sleep
Pain Disability Index (PDI)
It consists of seven questions assessing disability due to pain in the following domains: family/home, recreation, social activities, occupation, sexual behavior, self-care, and life support activities. Each item is rated on an 11-point scale (0= no
disability to 10= total disability) and the responses are summed. The PDI is also sensitive to change following
pain treatment
Sickness Impact Profile (SIP)
behaviorally based
checklist of 136 yes/no items, measuring psychosocial and
physical dysfunction across 12 categories of functioning: sleep and rest, eating, work, home management, recreation and pastimes, ambulation, mobility, body care and movement, social interaction, alertness behavior, emotional behavior, and communication
Roland-Morris
Disability Questionnaire
With only 24 questions, it was developed from a subset of SIP items and tailored for more focused use with chronic low back pain patients. This measure has become one of a
select group of standard outcome measures in the back pain literature
Chronic Disability Index (CDI)
a short (nine-item) yes/no checklist covering nine general activities that are typically difficult for people with back pain, such as walking, sleeping, putting on footware
Oswestry Low Back
Pain Disability Questionnaire,
a brief scale that provides a percentage score reflecting the amount of restriction that pain imposes on the individual. Scores have been shown to
be sensitive to treatment.
Negative Affect
the assessment
of negative affect, such as depression and anxiety, as well as negative cognitions is an essential component of pain assessment
Beck Depression Inventory (BDI)
multiplechoice
measure that asks individuals to endorse descriptive statements in 21 areas of depressive symptomatology, such
as sadness, energy level, concentration, guilt, and suicidal
ideation
Center for Epidemiological Studies Depression
Scale (CES-D)
originally developed for use in general population epidemiologic studies. Respondents are asked
to report the frequency with which they have experienced each of 20 symptoms during the past week on a 4-point scale
Zung Depression Inventory
which may be more appropriate for medical populations and offers the advantages of allowing a lower reading level and interview based
administration
Beck Anxiety Inventory (BAI)
developed to assesses
anxiety and discriminate it from depression.The scale consists of 21 items, each describing a common symptom
of anxiety. The respondent is asked to rate how much he or she has been bothered by each symptom over the past week on a 4-point scale ranging from 0 to 3
Pain Anxiety Symptoms Scale (PASS)
The PASS uses a 6-point scale and asks respondents to rate the frequency with which they experience several dimensions of anxiety, including somatic, cognitive, fear, and escape/ avoidance concerns
Closely interconnected with negative affects among individuals
with chronic pain are
negative cognitions—habitually maladaptive
ways of perceiving and thinking about situations— which can lead to a cascade of negative emotions and
behaviors
Catastrophizing
a strong anticipation of pain and reinjury or negative thoughts regarding pain-related experience, referred to as catastrophizing can lead to fear-related
avoidance of activity. These fears can produce a negative
reinforcement loop supporting the persistence of avoidance behaviors and functional limitations
Survey of Pain Attitudes–Revised
57-item instrument utilizing a 5-point Likert scale, assessing seven pain-specific attitudes, including perceptions of pain control, disability, and harm, as well as beliefs surrounding pain medication, the role of emotions in their pain experience, and the expectation that other people should be more
supportive of their pain concerns
Pain Beliefs and
Perceptions Inventory
16 items that tap three
dimensions of pain-related beliefs: future expectancies about pain and its persistence, the nature of pain and its
symptomatology, and self-blame surrounding pain
Pain Catastrophizing Scale
designed to measure individuals’ tendencies to focus on pain-related thoughts and exaggerate the significance of painful stimuli
Kinesiophobia
term for excessive fear of pain and reinjury with physical movement, which can lead to avoidance behaviors and may serve to exacerbate and maintain pain-related disability
Tampa Scale of Kinesphobia
17 items and assesses excessive fear of
physical activity related to the perceived threat of pain
Fear-Avoidance Beliefs Questionnaire
16 items that measure beliefs concerning the
risk of harm from general physical activities and also
from work-specific activities
Locus of control
Pain Locus of Control scale
an individual’s belief about his or her ability to influence outcomes in life. As applied
to chronic pain, locus of control refers to the extent to which patients believe they can influence or ameliorate
the intensity and impact of their pain experience
Coping
Coping involves the use of diverse strategies and techniques
in an effort to manage a variety of stressors, including pain.
Coping Strategies
Questionnaire
50-item measure assessing the extent to which patients engage in a variety of cognitive
and behavioral coping strategies when they experience pain,
including diverting attention, reinterpreting pain sensations,
coping self-statements, ignoring the pain, praying or hoping, increasing activity, and perceiving a measure of control over the pain
Chronic Pain Coping Inventory
65-item scale focused on behavioral strategies of coping that might be encouraged, or discouraged, in a multidisciplinary pain treatment program, including guarding, resting, asking for assistance, relaxation, task persistence, exercise/ stretch, seeking social support, coping self-statements, and medication use
Minnesota Multiphasic Personality Inventory
(MMPI) and its successor, the MMPI-2
instrument for measuring
psychopathology and personality variables.
The MMPI-2
is a measure with 567 true/false items, yielding three core validity scales and 10 clinical scales. The validity scales
determine the patient’s response set and motivation. The 10 clinical scales tap such dimensions such as concern with bodily symptoms, depression, defensive strategies,
rebelliousness and antisocial tendencies, suspiciousness,
worry and anxiety, and odd thinking. In addition to the primary clinical scales, the MMPI-2 has numerous subscales
that measure more specific symptoms, traits, and behaviors, including: anger, family problems, social alienation, addiction potential, and negative treatment indicators
Millon Clinical Multiaxial Inventory–III
has 175 true/false items, yielding 14 personality disorder scales (e.g., avoidant, dependent, passive-aggressive, and
histrionic) and 10 clinical syndrome scales (e.g., anxiety, somatoform, mood disorders, and substance abuse). While
originally developed for psychiatric populations, the scale
has been used with pain populations to assess levels of
psychopathology and predict back surgery outcomes
Symptom Checklist-90-Revised (SCL-90-R)
a shorter instrument that has been used for assessing psychopathology
among chronic pain patients. With 90 items,
the SCL-90-R assesses nine different types of psychological disturbance and yields three global measures of
distress
Two Comprehensive medical and psychological evaluations included in screening for
substance use and abuse
CAGE and AUDIT
CAGE
The most widely used, the CAGE, is typically administered verbally and is comprised of four
screening questions:
(1) Have you ever tried to Cut down on
your alcohol or drug use?
(2) Do you get Annoyed when people comment on your drinking or drug use?
(3) Do you
feel Guilty about things you have done while drinking or using drugs? (4) Do you need an Eye opener to get started
in the morning?
A positive response to two or more of these
questions is indicative of substance abuse.
Multidimensional Pain Inventory (MPI)
multidimensional
measures used in the evaluation of pain and its emotional and behavioral correlates. 56-item measure assesses psychosocial, cognitive, and behavioral aspects of pain, including pain severity and interference; activity levels, including household chores
and work; family relationships and social activities; pain specific
support from spouse or partner; perceived life
control; and negative affect. This measure is valuable in its ability to assess multiple dimensions of pain, its relative brevity, and its demonstrated sensitivity to treatment
effects. In addition, the MPI provides overall classification of people’s coping styles as being “dysfunctional,” “interpersonally
distressed,” or “adaptive coper.
Millon
Behavioral Health Inventory (MBHI)
its successor is the Millon Behavioral Medicine Diagnostic (MBMD)
With 150 items, the MBHI assesses multiple relevant domains, including coping styles (e.g., introversive, inhibited, confident, cooperative) and psychogenic attitudes (e.g., recent stress, premorbid pessimism, somatic anxiety)
Millon Behavioral Medicine Diagnostic (MBMD)
165 true/false items, the
MBMD assesses a wide range of domains, including: negative
health habits (e.g., smoking, inactivity, alcohol, and drug use), psychiatric indications (e.g., anxiety, depression), coping styles, stress moderators (e.g., future pessimism, social isolation, and pain sensitivity), and treatment prognostics
(e.g., problematic compliance, utilization excess, and
medication abuse)
Battery for Health Improvement–II
designed to assess the biopsychosocial variables relevant for pain patients. Normed on patients in physical rehabilitation and chronic pain treatment settings, the BHI-II has 217 items and offers information about several domains of functioning, including physical symptoms (e.g., somatic, pain, and
functional complaints); affective functioning (e.g., depression,
anxiety, and hostility); personality and behavior problems
(e.g., substance abuse and chronic maladjustment); and
psychosocial issues (e.g., family dysfunction, violence history,
and doctor dissatisfaction)
European Federation of IASP Chapters consensus document on neuromodulation treatment of pain that established psychosocial exclusion criteria for
spinal cord stimulators (SCS) implantation
(1) major psychiatric disorders (active psychosis, severe depression or hypochondriasis, and somatization disorder); (2) poor compliance and/or insufficient understanding of the therapy; (3) lack of appropriate social support; (4) drug and alcohol abuse; and (5) drug-seeking behavior
Additional risk factors to assess for
SCS implantation
Additional risk factors to assess include unrealistic expectations for pain treatments, cognitive deficits that
impair ability to understand, or manage, an implantable device, presence of active suicidal or homicidal intentions, severe sleep disturbance, the presence of personality disorders, and pain-related litigation
Psychological evaluation prior to SCS several goals
These evaluations have several goals,
including
(1) screening for major psychopathology and
cognitive impairments, (2) assessing treatment expectations and ability to follow through on post intervention
care and rehabilitation, (3) recommending interventions to address psychosocial factors that may impede optimal outcome,
(4) educating the patient as to the procedure and
their role in maximizing treatment outcome, and (5) identifying the individual’s psychosocial strengths that aid in recovery
Pseudoaddiction
it is not a true signal of opiate misuse, as much as it reflects inadequate pain relief
Pain Medication Questionnaire
and the Screener and Opiate Assessment of Patients with Pain–Revised
Self-report measures to
assist in this assessment are in the early stages of development of addiction
behavioral observations and standardized testing can be utilized for exaggeration ad malingering
(1) inconsistencies between physical
findings and the patient’s self-presentation,
(2) overly
impaired performance, (3) lack of specific diagnostic signs of impairment,
(4) nonorganic physical findings,
(5) evidence derived from psychological testing
