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PART THREE  EVALUATION OF THE PAIN PATIENT

A number of different observational procedures have been developed to identify and quantify pain behaviors. Structured methods that require patients to engage in a set of behaviors during which their behavior is observed and rated have been pro- posed by Keefe and colleagues. 106,107 Such structured approaches may be useful in research studies but can be cumbersome in clin- ical settings. Several investigators have developed observational Pain Behavior Checklists 108,109 that can be used in any setting. Although they have the advantage of efficiency, these methods may be less appropriate to compare among patients who are viewed in different contexts (e.g., during a physical examination or interview). As noted, the context may influence the behaviors observed. For example, the nature of pain behaviors observed might be quite different during a physically demanding exam- ination compared to an interview. The number and nature of pain behaviors might be influenced by the presence of signif- icant others during the observation period. At a minimum, it is important to note the context in which the behaviors were observed. Studies using Pain Behavior Checklists have found a significant association between these self-reports and behavioral observations. A variant of this observational procedure was de- veloped by Kerns and colleagues 110 who developed a self-report version in which patients endorsed specific behaviors that they engaged in when they were experiencing pain. Facial expressions and muscle patterns can provide objective, fine-grained analysis of the subjective experience of pain. 111 For- mal assessment of facial expression has been found to be valuable in research but may be too complex for use in a clinical setting. Uses of the health care system and analgesic medication are other ways to assess pain behaviors. Patients can record the times when they take medication over a specified interval such as a week. Despite the cautions regarding patient diaries noted, diaries can not only provide information about the frequency and quantity of medication but may also permit identification of the antecedent and consequent events of medication use. Antecedent events might include stress, boredom, or activity. Examination of antecedents is useful in identifying patterns of medication use that may be associated with factors other than pain per se. Similarly, patterns of response to the use of anal- gesic may be identified. Does the patient receive attention and sympathy whenever he or she is observed by significant others taking medication? That is, do significant others provide pos- itive reinforcement for the taking of analgesic medication and thereby unwittingly increase medication use? Assessment of Emotional Distress The results of numerous studies suggest that chronic pain is fre- quently associated with emotional distress, particularly depres- sion, anxiety, anger, and irritability. The presence of emotional distress in people with chronic pain presents a challenge when assessing symptoms such as fatigue, reduced activity level, decreased libido, appetite change, sleep disturbance, weight gain or loss, and memory and concentration deficits. These symptoms are often associated with pain and have also been considered “vegetative” symptoms of depressive disorders. Im- provements or deterioration in such symptoms, therefore, can be a result of changes in either pain or emotional distress. The BDI and BDI-2, 87,88 the Profile ofMood States (POMS), 112 the Hospital Anxiety and Depression Scale (HADS), 113,114 and Patient Health Questionnaire (PHQ-9) 115 have well-established reliability and validity in the assessment of symptoms of de- pression and emotional distress, and they have been used in nu- merous clinical trials in psychiatry and an increasing number of studies of patients with chronic pain. 116 In research in psychia- try and chronic pain, the BDI provides a well-accepted criterion of the level of psychological distress in a sample and its response to treatment. The POMS 112 assesses six mood states—tension– anxiety, depression–dejection, anger–hostility, vigor–activity,

fatigue–inertia, and confusion–bewilderment—and also pro- vides a summary measure of total mood disturbance. Although the discriminant validity of the POMS scales in patients with chronic pain has not been adequately documented, it has scales for the three most important dimensions of emotional function- ing in chronic pain patients (depression, anxiety, and anger) and also assesses three other dimensions that are very relevant to chronic pain and its treatment, including a positive mood scale of vigor–activity. Moreover, the POMS has demonstrated beneficial effects of treatment in some (but not all) chronic pain trials. 117,118 The HADS include seven items assessing anxi- ety and depression. One advantage of the HADS is that it was developed and standardized with medical patients rather than psychiatric patients. Shorter measures of anxiety (Generalized Anxiety Disorder [GAD]-7) 119 and depression (PHQ-9) 115 have been reported to provide reliable and valid assessments and might also be considered for research as well as clinical use. Any of these measures reasonable choices as brief measures of emotional distress. As noted previously, various symptoms of depression—such as decreased libido, appetite or weight changes, fatigue, and memory and concentration deficits—are also common. It is un- clear whether the presence of such symptoms in patients with chronic pain (and other medical disorders) should nevertheless be considered evidence of depressed mood or whether the as- sessment of mood in these patients should emphasize symptoms that are less likely to be secondary to physical disorders. 111,120 Assessment of Fear Many patients with chronic pain, especially those who attri- bute their symptoms to trauma, are fearful of engaging in ac- tivities that they believe may either contribute to further injury or exacerbate their symptoms. Avoidance of activities may, in the short term, lead to symptom reduction. But over time, re- striction of activities is likely to lead to decreased functional capacities as a result of deconditioning. Also, avoidance of ac- tivity has the unfortunate consequence of preventing correc- tive feedback where patients can learn about their erroneous beliefs. Health care providers may inadvertently contribute to avoidance of activity by providing patients with cervical col- lars that restrict neck movements and advising them to avoid activities that hurt (i.e., hurt 5 harm). They may contribute to patients’ anxiety that something is seriously wrong with their bodies by continuing to order sophisticated diagnostic tests in search of occult physical pathology. Self-report measures of fear of movement that might increase pain or physical damage are available (e.g., Tampa Scale of Kinesiophobia [TSK], Fear Avoidance and Beliefs Questionnaires [FABQ]). 121,122 Historically, psychological measures designed to evaluate psy- chopathology have been used to identify specific individual differences associated with reports of pain, even though these measures were usually not developed for or standardized on samples of medical patients. Because disease status and medica- tion can affect responses to such items, patients’ scores may be elevated, thereby distorting the meaning of their responses. As a result, a number of measures have been developed for use specif- ically with pain patients. Instruments have been developed to as- sess psychological distress; the impact of pain on patients’ lives, feeling of control, coping behaviors, and attitudes about disease, pain, and health care providers; and the patient’s plight. 123,124 Two particularly potent beliefs (i.e., self-efficacy and catas­ trophizing) held by patients have been demonstrated to play important roles in chronic pain. Self-efficacy is the conviction that one can successfully perform a certain task or produce a desirable outcome. 125 A major determinant of self-efficacy is Assessment of Beliefs, Coping, and Psychosocial Adaptation to Pain