Assessment 305TABLE 13.1 Screening Questions
Clinical Issues
Has the pain persisted for three months or longer despite appropriate
interventions and in the absence of progressive disease?
Does the patient report nonanatomical changes in sensation (e.g., glove
anesthesia)?
Does the patient seem to have unrealistic expectations of the health care
provider or treatment offered?
Does the patient complain vociferously about treatments received from
previous health care providers?
Does the patient have a history of previous painful or disabling medical
problems?
Does the patient have a history of substance abuse?
Does the patient display many pain behaviors (e.g., grimacing, moving
in a rigid and guarded fashion)?
Legal and Occupational Issues
Is litigation pending?
Is the patient receiving disability compensation?
Was the patient employed prior to pain onset?
Was the patient injured on the job?
Does the patient have a job to which he or she can return?
Does the patient have a history of frequent changing of jobs?
Psychological Issues
Does the patient report any major stressful life events just prior to the
onset or exacerbation of pain?
Does the patient demonstrate inappropriate or excessive depressed or
elevated mood?
Has the patient given up many activities (social, recreational, sexual,
occupational, physical) because of pain?
Is there a high level of marital or family con”ict?
Do the patient•s signi“cant others provide positive attention to pain
behaviors (e.g., take over their chores, rub their back)?
Is there anyone in the patient•s family who has chronic pain?
Does the patient have plans for increased or renewed activities if
their pain is reduced?2.What is the magnitude of the illness? That is, to what ex-
tent is the patient suffering, disabled, and unable to enjoy
usual activities?
3.Does the individual•s behavior seem appropriate to the
disease or injury or is there any evidence of ampli“cation
of symptoms for any of a variety of psychological or so-
cial reasons or purposes?
We will focus on the next two questions, speci“cally, the ex-
tent of the patient•s disability and behavioral in”uences on
the patient pain, distress, and suffering.
Interview
When conducting an interview with chronic pain patients, the
health care professional should focus not simply on factual
information but on patients• and signi“cant others• speci“c
thoughts and feelings and they should observe speci“c be-
haviors. During an interview, it is important to adopt the pa-
tient•s perspective. Pain sufferers• beliefs about the cause of
symptoms, their trajectory, and bene“cial treatments will
have important in”uences on emotional adjustment and ad-
herence to therapeutic interventions. A habitual pattern of
maladaptive thoughts may contribute to a sense of hopeless-
ness, dysphoria, and unwillingness to engage in activity. The
interviewer should determine both the patient•s and the
spouse•s expectancies and goals for treatment.
Attention should focus on the patient•s reports of speci“c
thoughts, behaviors, emotions, and physiological responses
that precede, accompany, and follow pain episodes or exacer-
bation, as well as the environmental conditions and conse-
quences associated with cognitive, emotional, and behavioral
responses in these situations. During the interview, the
clinician should attend to the temporal association of these
cognitive, affective, and behavioral events; their speci“city
versus generality across situations; and the frequency of their
occurrence, to establish salient features of the target situa-
tions, including the controlling variables. The interviewer
seeks information that will assist in the development of po-
tential alternate responses, appropriate goals for the patient,
and possible reinforcers for these alternatives.
The health care provider should be alert forred flagsthat
may serve as an impetus for more through evaluation by pain
specialists. Table 13.1 contains a list of 20 issues that can be
stated as questions worthy of considering with patients who
report persistent or recurring pain. The positive responses to
any one or a small number of these questions should not
be viewed as suf“cient to make a referral for more extensive
evaluation, but when a preponderance of them are, referral
should be considered. Generally, a referral for evaluation
may be indicated where disability greatly exceeds what
would be expected based on physical “ndings alone, when
patients make excessive demands on the health care system,
when the patient persists in seeking medical tests and treat-
ments when these are not indicated, when patients display
signi“cant psychological distress (e.g., depression or anxi-
ety), or when the patient displays evidence of addictive be-
haviors such as continual nonadherence to the prescribed
regimen.
In addition to interviews, a number of assessment instru-
ments designed to evaluate patients• attitudes, beliefs, and ex-
pectancies about themselves, their symptoms, and the health
care system have been developed. Standardized assessment
instruments have advantages over semistructured and un-
structured interviews. They are easy to administer, require
less time, and most importantly, they can be submitted to
analyzes that permit determination of their reliability and va-
lidity. These standardized instruments should not be viewed
as alternatives to interviews but rather that they may suggest
issues to be addressed in more depth during an interview.