Course 5 Psychological Aspects of Chronic PainNelson Hendler, MD, MS,Former Assistant Professor of NeurosurgeryJohns Hopkins University School of MedicinePast president-American Academy of Pain Management
Research Methodology• Physicians want to know if a patient has a valid complaint of pain• Earlier research is flawed, because it say if a patient has pain and depression, the cause of the pain is the depression- a depressive equivalent.• Researchers never looked at the effect of pain over time.• You have to study a normal response to appreciate an abnormal response- study anatomy to recognize pathology.
4 Stages of Chronic Pain in an Objective Pain Patient- A Normal Response to Pain(Hendler, in Diagnosis and Treatment of Chronic Pain, Edited by Hendler, Long and Weiss, Wright-PSG, ’82)• Chronic pain patients go through 4 stages remarkable similar to the 5 stages a patient experiences when dying (Kubler-Ross-’69)- this is a normal response to pain.• Acute Stage 0-2 months –Pt. expects to get well, so no psychological changes are evident (MMPI is normal).• Sub-acute stage-2-6 months- Pt. had anxiety and somatic concerns develop (MMPI scales 1 & 3 are elevated)• Chronic stage 6 months-8 years- Pt. is depressed, because he is not getting well (MMPI has elevated scale 2, called a pain neurosis by Blumer, pain prone patient by Pilling, low back loser by Sternbach)• Sub-chronic stage-3-12 years Pt. resets goals-adaptation (MMPI scales 1 & 3 elevated, hypochondriasis and hysteria)
What are the Questions?• Does the patient have a valid complaint of pain?• Variables: pre-existing psychopathology, resultant psychopathology, negative tests, positive tests that do not correlate with the anatomical complaint of pain (i.e. L5-S1 disc on MRI: pain in top of thigh = L2-L3)• KEY Concept: Severe chronic pain produces consistent psychological and sociological responses in a patient, regardless of pre-existing or co-existing psychiatric disease.• If the response to pain is normal, believe the patient, not the tests, and keep looking• People with pre-pain psychiatric illness can also get medical illness. This is not conversion.
From; Hendler and Talo, Current Therapy of Pain, edited by Kathy Foley and Richard Payne, BC Decker, ’89
Rational Clinical Approach• Patients can have both psychiatric disease and organic pathology co-existing• Schizophrenics get brain tumors, and hysterics get disc disease. Psychiatric disease does not confer an immunity against getting a medical disease.• Treat each patient as if they have organic pathology.• Give patient the benefit of the doubt.• See www.MarylandClinicalDiagnostics.com for the Pain Validity Test
Types of Chronic Pain Patients Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven Press, ‘81• Objective Pain Patient: Good pre-morbid adjustment, objective findings, and goes through the 4 stages of pain (case study: Car Exec.) (87%-94% of all chronic pain patients)• Exaggerating Pain Patient: poor pre-morbid adjustment, minimal findings, and absence of depression (case study: hysterical scoliosis).• (Between 6% to 13% of all chronic pain patients)• Mixed Objective-Exaggerating Pain Patient: poor pre-morbid adjustment, objective findings and very difficult to manage by medical or psych (case study: sexual abuse, histrionic, TOS, disc)
Objective Pain Patient-A normal responseCase Study: A 56 year old executive for a Big Three auto maker was marriedfor 25 years, had three children, none on drugs, all of whom were in college,and was earning over $1,000,000/year. He was working on his boat, when theengine fell, and traumatically amputated his thumb. He went to work the nextday, and continued to work, and he expected the pain to subside. However,after two months, the pain in his thumb became so severe, that he could notconcentrate, nor sleep. He was diagnosed with a neuroma in the stump of thethumb. Any sensation to the stump would cause severe pain to shoot up hisarm. When he was seen at a hospital in Baltimore, he had been suffering fortwo years. He scored 14 points on the Mensana Clinic Pain Validity Test,putting him the Objective Pain Patient category. He was suicidal, sleeping onlytwo hours a night, and was on three types of narcotics, sleeping medication,and diazepam. He wanted to divorce his wife because he felt like a burden toher. He was severely depressed and had never been depressed before theonset of pain. He was so desperate to get rid of his pain that he had a thalamicstimulator put into his brain. Unfortunately, this gave him only partial relief.Eight years after the onset of his pain, he was less depressed, was offnarcotics, and sleeping medication, and was getting four hours of sleep anight. He still had pain, but had adjusted to the pain. He had retired from theauto company. (Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, RavenPress, New York, 1981).
Exaggerating Pain Patient-The Abnormal Response to PainA 43 year old woman was hospitalized in Baltimore, complaining of markedscoliosis, that had just developed, in the past year. Further evaluation did notverify the typical radiological findings seen with a constant scoliosis. She scored24 points on the Mensana Clinic Pain Validity Test, putting her in theExaggerating Pain Patient category. A trial with an Amytal (truth serum) interviewfailed to resolved the scoliosis, but when the patient was anesthetized, thescoliosis resolved temporarily. Further Amytal interviews revealed the patienthad a stormy marital relationship, and she avoided sex with her husband,because he was abusive. The patient was reassured she need not have sex withher husband if he was abusive. The next day, she walked upright, and continuedin this posture, until her husband visited. The day of the visit, the scoliosisreturned. Additional Amytal interviews revealed she had been abused as a child.She had a she had been afraid to seek divorce from her husband, but with socialworker intervention, she found the support to do so. The scoliosis resolved. Onfive year follow-up, she was divorced, and remained free of scoliosis. (Hendler, N,Filtzer, D, Talo, S, Panzetta, M, and Long, D, Hysterical Scoliosis Treated with AmobarbitalNarcosynthesis, The Clinical Journal of Pain, 2:179-182, 1987).
Mixed Objective-Exaggerating Pain PatientThe patient was a 33 year old white female, married for the third time. She had agradual onset of lower neck and right arm pain. She complained of “excruciatingpain,” “devastating pain,” and “unbearable pain.” She arrived for her first interviewwearing heavy blue eye-shadow, bright red-lipstick, three rings on each hand,reeking of perfume, wearing a low cut revealing blouse, and very short skirt. Sheused superlatives for everything. Despite her clear histrionic personality disorder,she scored 20 on the Mensana Clinic Pain Validity Test, placing her in the MixedExaggerating-Objective pain patient category. Her MMPI scores showed elevatedscales 1 and 3: “a conversion V.” Her husband was 20 years older than she was,and was a very successful business man, who provided her every creaturecomfort, from the finest cars, to a maid. She clearly was overusing her narcoticmedication. Her pain was made worse with extension of her neck, and shesubsequently had C4-7 facet blocks which gave her 80% relief of her neck pain.Facet denervations gave her 50% relief of her neck pain. After this treatment, shewas able to improve her level of functioning, and eliminate the use of narcotics.(Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven Press, New York, 1981).
McGill-Melzack Pain Test• RONALD MELZACK, PhD is E. P. Taylor Professor of Psychology at McGill University and research director of the Pain Clinic at the Montreal General Hospital.• McGill Melzack Pain Test measures the subjective pain experience using 3 categories of word descriptors: sensory, affective and evaluative.• Also contains intensity scale and other items to describe pain.• Designed to provide a quantitative measure of pain, so it can be used to measure improvement
Minnesota MultiphasicPersonality Inventory (MMPI):• This is a self administered test, with choices of answers which are only true or false.• There are 566 questions,• The test was developed to determine personality types in individuals, i.e. manic depressive, schizophrenic, hysteric, depressive, obsessive, hypochondria, etc.• The MMPI II was recently released
Minnesota Multiphasic Personality Inventory (MMPI):• Sample questions from the MMPI• I like mechanics magazines – True or False?• I hear voices and don’t know where they are coming from- True or False?• I have more pain than most of my friends- True or False?• From these answers, the tests predicts personality types, & then from personality types said it could predict if a patient had real pain
Minnesota Multiphasic Personality Inventory (MMPI): lack of predictive capabilities• Hagedorn et al (Pain, ’84) followed 50,000 patients for 25 years. This is the only prospective study on MMPI ever done.• They all received the MMPI when they first entered the Mayo Clinic system.• 68 of them had back surgery.• No difference in pre-surgery MMPI between those who did do well or didn’t do well with surgery.
Validating the Complaint of Pain• MMPI is not consistent in predicting the presence or absence of organic pathology. Not one single scale ever correlates, consistently, with the presence or absence of organic pathology (Hendler et al, Pain, ’85, J. Occ. Medicine,’88, J. Neurolog & Ortho. Med. & Surgery, ’85, Clinical Neurosurgery, ‘89)
Longitudinal Studies on DepressionPatients admitted to Mensana Clinic:77% of the chronic pain patients were depressed, as confirmed by Beck scores.However, 89% had never been depressed before the onset of their pain ( Hendler, Clinical Neurosurgery, ‘89)After six months or more, chronic pain produces depression (Hendler, J. Clinical Psych, ’84)
Overused Psychiatric Diagnoses in Chronic Pain Patients• Conversion reaction is defined as an unconscious manifestation of a physical problem (usually visible) without an organic basis (300.11- DSM-IV).• Malingering is defined as a conscious attempt to deceive for personal gain (316.V65.2-DSM- IV). Patients refuse to go for tests.• Pain Disorder (307.80- DSM-IV) defined as a pain for which is there is no medical explanation.• Somatoform Disorder (300.81- DMM –IV) defined as a cluster of 4 pain, 2 GI, 1 sexual and 1 pseudo-neurological symptoms without medical diagnosis.
Overused Psychiatric Diagnoses in Chronic Pain Patients• Conversion reaction: What is the incidence? Kemp, Am. J. of Insanity, 1913 less than 1% of admission to Phipps were conversion.• Stephens, J. of Nervous and Mental Disease, ’62, less than 2% of Phipps admits were conversion• Hendler. N. Neurosurgical Management of Pain , ’97, Edited by Richard North, MD and Robert Levy, MD, Chap. #2, reports only 3/6,000 chronic pain patients with conversion reactions.
Overused Psychiatric Diagnoses in Chronic Pain Patients• Slater, E. Br. Med. J. ’65 did 9 year follow-up on 85 patients diagnosed as conversion hysteria at Queens Square Neurological Hospital in London.• Only 7/85 were confirmed as conversion• The rest has atypical myopathy, trigeminal neuralgia, disseminated sclerosis, dementia, thoracic outlet syndrome, epilepsy, vestibular lesions, Takayasu’s syndrome, neoplasms, schizophrenia, somatizing disorders, cord compression, and endogenous depression.
Overused Psychiatric Diagnoses in Chronic Pain Patients1) The incidence of hysterical conversionreaction is small in a general psychiatricpopulation (1%-2% of admissions). 2)The incidence of hysterical conversion in achronic pain population that is properlydiagnosed, is even smaller (3/6000 or .05%).3) Even after diagnosed with conversionreaction, there is less than a 10% chance thepatient really has this, and most likely hasmedical disease.
Overused Psychiatric Diagnoses in Chronic Pain Patients• Conversion reactions (300.11 DSM IV), such as paralyzed limb, blindness, or falling -visible signs• Not in DSM IV- The disorder does not produce distress in the patient (“La belle indifference”).• The symptoms will remit with amobarbital narcosynthesis, at adequate doses (>450mg)• Hendler et al Clinical J. of Pain, ‘87 described a case of hysterical scoliosis diagnosed by the orthopedic surgeon, which did not respond to Amytal, but responded under general anesthesia.
Example of Conversion Disorder• Hysterical Scoliosis-a woman leaning to the side, without an organic basis for this• Note-visible symptom – “I am sick.”• Note-responded to narcosynthesis.• Note – represented an unexpressed psychological conflict• Pain is a bad conversion symptom, because it is not visible, and even people with real pain have trouble convincing people they have something wrong.
Overused Psychiatric Diagnoses in Chronic Pain Patients• Malingering: No statistics about frequency (Hendler and Talo, Current Therapy of Pain, edited by Kathy Foley and Richard Payne, BC Decker, ’89).• Pain Disorder is defined as “pain for which is there is no medical explanation.” However, if 40%-67% of chronic pain patients are misdiagnosed medically, then these patients receive a faulty psychiatric diagnosis, because of a poor medical diagnosis.• Depressive Equivalents: Depression causes pain.• Circular logic if the diagnostic criteria in DSM-IV for somatoform disorder, pain disorder, and depressive equivalents is “Pain without a medical explanation.” then a poor medical work-up lead to these DSM “diagnoses.” They becomes self fulfilling prophecies.
Suicide and PainChronic pain patient commit suicide at a higher rate than the general population (Fishbain et al Clin. J. of Pain, ‘91).White males with pain complete suicide at a rate 2X higher than the general population.White females with pain complete suicide at a rate 3 X higher than the general population.White males with pain, involved in workers compensation litigation complete suicide at a rate 3 X higher than the general population.Any threats of suicide from a chronic pain patient must be taken seriously.Worse yet, suicide attempts are not gestures
Beck Depression Inventory (BDI)• Aaron Temkin Beck (born July 18, 1921) is an American psychiatrist and a professor emeritus in the department of psychiatry at the University of Pennsylvania. He is widely regarded as the father of cognitive therapy• His Beck Depression Inventory (BDI, BDI- II) is a 21-question multiple-choice self- report inventory, one of the most widely used instruments for measuring the severity of depression.
Beck’s Two-factor approach to depression• Depression can be thought of as having two components:• the affective component (e.g. mood)• and the physical or "somatic" component (e.g. loss of appetite).• The BDI-II reflects this and can be separated into two subscales. The purpose of the subscales is to help determine the primary cause of a patients depression.
Beck Depression Inventory (BDI)• The development of the BDI represented a shift in health care professionals view of depression from a Freudian, psychodynamic perspective, to one guided by the patients own thoughts or "cognitions".• The BDI was developed to provide a quantitative assessment of the intensity of depression• It can monitor changes over time, and track improvement of depression
The Hopkins Symptom Check List (SCL)-90• SCL-90-R has 90 items.• It takes 12–15 minutes to administer• Developed by Len Derogaitis,PhD• It has nine scores along primary symptom dimensions somatization, obsessive- compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism-These are personality states• States change over time, unlike the MMPI, which measures traits, which don’t change
Available Help• Pain Validity Test is available on Internet, at www.MarylandClinicalDiagnostics.com, to validate pain, by predicting the presence or absence of organic pathology.• It allows a physician to improve diagnostic accuracy, and serves as a screening tool to help get an accurate diagnosis.• There are 7 articles about the Pain Validity Test, involving 794 patients.• The test has 32 questions, and takes only 15 minutes to administer & results in 5 min.• It is available in English and Spanish
The Pain Validity Test• The test was developed by a team of researchers from Johns Hopkins Hospital• Based on the most recent publication on the Internet version of the test, it can predict who will have an abnormality on an objective medical tests with 95% accuracy• The Pain Validity Test can predict who will have no abnormalities or only mild abnormalities with 85% accuracy• After the test is administered, the results are available within 5 minutes
The Pain Validity Test• Can assess the validity of the complaint in the chronic pain patient, regardless of pre- existing or co-existing psychological problems. Far better than the MMPI• It adheres to the precept that the development of pain is independent of personality traits, unlike MMPI research• Developed by Johns Hopkins Hospital staff, led by Nelson Hendler, MD, MS, Assist. Prof.• Go to www.MarylandClinicalDiagnostics.com
Scattergram of Computer Scored Pain Validity Test. On the left, 3* is a severe abnormality, 2 a moderate abnormality, 1 a mild abnormality, and 0 is no abnormality on at least one objective medical test. At the bottom, 8-25represent the score on the Pain Validity Test. 17 or less is an Objective Pain Patient, 21 point or higher is an Exaggerating Pain Patient*3 65/69 = 95% 2 Exaggerating Objective Pain Patient Pain Patient1 11/13 = 85%0 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Explanation of the Scattergram• 87%- to 94% of clients score as an objective pain patient on the Pain Validity Test.• Look at Scattergram- Objective Pain Patients have a 95% chance of having moderate or severe abnormalities on at least one objective measure of organic pathology, such as EMG nerve conduction studies, root blocks, facet block, provocative discograms, MRI, CT, etc. Medical articles prove that the MMPI has no predictive medical capabilities. Insurance companies often claim that the MMPI does, but can’t prove it.• Pain Validity Test can identify patients who will not have medical abnormalities with 85% accuracy. Only 6%-13% of patients are exaggerating
Conclusions• The current methods of assessing chronic pain are not cost effective, and not accurate.• Misdiagnosed patients cost insurance companies much more than fraudulent cases.• The Pain Validity Test is a reliable method for detecting organic pathology regardless of pre- existing psychological problems.• Psychological care alone has not been documented as effective in chronic pain patient treatment. Depression is caused by chronic pain• Any clinician should demand Evidence Based Medicine proof of efficacy of treatment.• See www.MarylandClinicalDiagnostics.com