Psychology Pain Management Jeff Baker, Ph.D. UTMB Psychology Training Program Chief Psychologist, Anesthesiology, Cardiothoracic Surgery, Spine Surgery, Adult Rehabilitation Center

Significant Risk Factors for Chronic, Disabling Low-Back Pain: Update 2002  Known Risk Factors MMPI Scale 3 Elevation MMPI Scale 3 Elevation Poor Quality of Life Poor Quality of Life Depressed Depressed Low activity/high pain behaviors Low activity/high pain behaviors Negative beliefs/fear of pain Negative beliefs/fear of pain Thacker, I., Hadjipavlou, A., Volk, R., Baker, J., and McCoy, C. (1997) “Comparison of Seven Psychometric Instruments Used in Evaluation of Patients with Low Back pain.” The Journal of Bone and Joint Surgery, Orthopaedic Proceedings, Supplement I, Volume 79-B.

Important Risk Factors  Age  Severe Psychological stress or abuse  Subjective Pain Intensity  Substance Abuse  Compensation & Unemployment  5+ Positive Waddell Signs

Patients Would like a Simple & Quick Fix It is not always that easy, but sometimes it provides enough relief to recover.

Psychological Disorders (DSMIV) associated with Chronic Pain ADJUSTMENT DISORDERS  With Depressed Mood (309.0)  With Anxiety (309.24)  With mixed anxiety and depression (309.28)  With disturbance of Conduct (309.3)  With mixed disturbance of emotions and conduct (309.4)  Adjustment Disorder Unspecified  Low back pain (724.2)

Psychological Assessment & Patients with Chronic Pain  Clinical Interpretation varies based upon psychosocial factors and validity scales.  Assists the patient with understanding psychological component of pain.  Objective measures assist in identifying the extent of possible severe psychopathology.  Assists surgeons and anesthesiologists in a better understanding of psychological dynamics of patients with chronic pain.

Psychological Assessment  Clinical Interview  Psychological Eval MMPI2 BDI II Coping Skills Questionnaire

Characteristics of Patients with Debilitating Chronic Pain  Constant or recurrent pain present beyond the normal healing period.  Complaints and response to pain disproportionate to objective findings.  Signs of symptom magnification on objective physical, functional, and psychological evaluation (present in 50% of patients).  No response or short period of response to traditional treatment (conservative measures or surgery).  Reduction in work and physical and recreational activities.  Significant depression, with anxiety, increased irritability, and poor interpersonal relationships.  Dissatisfaction with the medical care received and/or anger at rehabilitation professionals.  Participation in “doctor-shopping”.  Analgesic or ETHO abuse.

Characteristics of Chronic Pain Continued  Preoccupation with finding a cure for pain and rejection of the idea that they may have to live with physical difficulties.  Denial of any possible relationship to psychological issues.  Refusal to allow regimens involving patient effort.  Pursuit of disability claims and litigation.

Many Patients Want Surgery or Meds Without Much Personal Effort

0-13 Minimal; Mild; Moderate; Severe Beck Depression Inventory (BDI)

Minnesota Multiphasic Personality Inventory-2 Developed in 1942 Renormed in Validity Scales Lies, Faking (Over reporting/Under reporting symptoms), & K Correction

Clinical Scales of the MMPI2  Scale 1 - Hypochondriasis  Scale 2 - Depression  Scale 3 - Conversion Hysteria  Scale 4 - Psychopathic Deviate  Scale 5 - Masculinity/Femininity  Scale 6 - Paranoia  Scale 7 - Psychasthenia  Scale 8 - Schizophrenia  Scale 9 - Hypomania  Scale 10 - Social Introversion

T Score of 50=Mean; >65 T Score Clinical Elevation Clinical Use of the MMPI2 & Patients with Chronic Pain

Psychology Surgical Rating=3.5 MMPI2 Case Example #1  Evaluated for spinal fusion  Horse/MVA 1998  Cannot sit, stand, or walk for extended periods  Elevated 1 & 3 Scales  Pt has 6 month history of low back pain  Not currently employed, wants to go back to work  Financial stressors  Positive family support

Psychology Surgical Rating = 3.0 MMPI2 Case Example #2  Patient evaluated for decompression and fusion  No clinical pathology  No significant elevations on MMPI  Unemployed for 1 year  No significant support system (occasional boyfriend)  Cheerful, conversational, exhibited no pain behaviors  Reports no significant psychosocial stressors or litigation

Psychology Surgical Rating 2.5 MMPI2 Case #3  Patient evaluated for fusion  Patient has major elevation on 6 scale  Slight elevations on 1 & 3 scales  Ex Policeman fired after 8 years  Recently Divorced  Diagnosed w/OCPD  1 st Time in “indigent” care system  Patient fired his last M.D.

No Psychology Surgical Rating MMPI2 Case Example #4  Patient was referred for pain management  Not considered a surgical candidate  Elevations on 2, 6, 8, 3, 1 & 7 Scales  Currently unemployed  Pursuing litigation  Reports Significant depression  Reports Significant psychosocial stressors, some support

Psychology Surgical Rating = 1.0 MMPI2 Case #5  Patient evaluated for 3 level fusion  Serious psychopathology  Pt has hx of serious mental illness  Elevations on 8, 6, 2, 4, 7, 3, 0, 1 Scales  Pt has difficulty with reality based decisions

Quality of Life  Work  Avocation/Hobbies  Family  Spirituality  Mobility  Financial  Health Care System

McGill-Melzack Pain Questionnaire  Pain Drawing  Patient Self Reports where their pain is located  Diffuse Pain = More Complicated Results  Three Scoring Methods Available (Margolis, McCoy, Wiltse), Margolis had.99 interrater reliability.

Psychological Techniques for working with Patients with Chronic Pain.  Relaxation Training  Biofeedback  Visualization  Cognitive Restructuring  Behavioral Modification  Stress Management  Hypnosis

Surgery Rating by Psychology  5 – Excellent Candidate  4 – Good Candidate  3 – Moderate Candidate  2 – Significant Concerns  1 – Serious Psychological Concerns

Pain Psychology Services at UTMB  Anesthesiology Pain Clinic  Cardiothoracic Surgery Clinic  IBS Clinic  Consultations (Oncology, Adult Rehab)