Page 107 Guide to Pain Management in Low-Resource Settings

Psychological Evaluation of the Patient with Chronic Pain 95

to detect the patient’s complaints and attitude. It is not Emotions
possible to gather all information within an interview, • Extreme fear of pain and impairment
because of the diff erent issues surrounding response to • Depressive reactions
pain. Highly structured methods exist in the fi eld of re- • Increased awareness of physical symptoms
search, which are often not practical in daily use due to • Helplessness/resignation
time constraints. Nonstandardized formats make it eas-
Behavior
ier to focus on topics that are discovered to be essential
during the discussion. It is easier to diagnose nonverbal • Distinctly cautious behavior
actions such as avoidance of movements or facial ex- • Withdrawal from normal daily activities
pressions of emotions within the interview, along with • Distinctly preventive behavior
emotions like sadness or anger. • Extreme pain behavior (including intensity)
• Disturbance of sleep
What is the format for an interview
• Abuse of medication
specifi c to chronic pain with underlying
psychological aspects? Family
An interview should include questions about previous • A partner who is overprotective and too caring
pain experience and about the development of pain, • A history of dependency (medication/drugs)
individual explanations about the origin of the pain, • A family member is also a “pain patient”
and the treatment objectives for the patient. Assess- • Serious confl icts in partnership or family
ment of the patient’s behavior includes information on
Workplace
reduction of activities and the avoidance of everyday
• Conviction that work damages the body
activities, including physical activities, because of the
fear of an increase in pain. It is also important to eval- • Little support in job
• No interest shown by boss or colleagues
uate the use/overuse of medication and compliance
[16], in order to detect possible hints of drug abuse. • Dissatisfaction with job
• Motivation to relieve strain
Questions might include:
• “When do you have to take the medication?” Given Diagnosis/Treatment
• “How often do you take it?”
• Cautious behavior/impairment supported by
• “How much do you have to take for pain relief?”
doctor
• “What other medications have you tried?”
• Numerous (partly contradictory) diagnoses
Th e assessment of possible comorbid disorders such
• Fear of malignant disease
as depression, anxiety, somatoform disorders and post-
• Passive treatment prescribed
traumatic stress disorder (PTSD) is another important
• High level of health care utilization
purpose of the psychological interview, along with as-
• Conviction that only somatic treatment will lead
sessment of risks of chronifi cation.
to alleviation
What are further possible risks of • Dissatisfaction with previous treatment
chronifi cation?
Why is it important to assess individual models
A helpful system for the identifi cation of psychosocial of explaining pain and its expression?
risk factors, known as “Yellow Flags,” was developed by
Individual models of explaining the development of pain
Kendall et al. [4], mainly for patients with back pain, but
are dependent on sociocultural and ethnic aspects. Th e
it may also be applicable to other pain syndromes:
meaning and expression of pain and suff ering are deter-
Cognition/Beliefs mined by social learning. Response to and expression

• Exercise/strain is harmful of pain are determined by culture as a conditioning in-
• Pain must disappear completely before activity is fl uence. An early belief in the development of pain was
resumed the “foreign body theory,” where pain that did not have
• Catastrophizing an identifi able cause, such as headache, was thought to
• Conviction that pain is uncontrollable be connected to supernatural powers. Magical objects
• Fixed ideas on development of treatment were thought to enter orifi ces and be responsible for