This power point delineates the various diagnoses associated with chronic pain.

1. Course 5
Psychological Aspects of
Chronic Pain
Nelson Hendler, MD, MS,
Former Assistant Professor of Neurosurgery
Johns Hopkins University School of Medicine
Past president-American Academy of Pain Management

2. 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.

3. 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)

4. 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.

5. From; Hendler and Talo, Current Therapy of Pain, edited by Kathy Foley and Richard Payne, BC Decker, ’89

6. 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

7. 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)

8. Objective Pain Patient-A normal response
Case Study: A 56 year old executive for a Big Three auto maker was married
for 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 the
engine fell, and traumatically amputated his thumb. He went to work the next
day, 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 not
concentrate, nor sleep. He was diagnosed with a neuroma in the stump of the
thumb. Any sensation to the stump would cause severe pain to shoot up his
arm. When he was seen at a hospital in Baltimore, he had been suffering for
two years. He scored 14 points on the Mensana Clinic Pain Validity Test,
putting him the Objective Pain Patient category. He was suicidal, sleeping only
two 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 to
her. He was severely depressed and had never been depressed before the
onset of pain. He was so desperate to get rid of his pain that he had a thalamic
stimulator put into his brain. Unfortunately, this gave him only partial relief.
Eight years after the onset of his pain, he was less depressed, was off
narcotics, and sleeping medication, and was getting four hours of sleep a
night. He still had pain, but had adjusted to the pain. He had retired from the
auto company. (Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven
Press, New York, 1981).

9. Exaggerating Pain Patient-The
Abnormal Response to Pain
A 43 year old woman was hospitalized in Baltimore, complaining of marked
scoliosis, that had just developed, in the past year. Further evaluation did not
verify the typical radiological findings seen with a constant scoliosis. She scored
24 points on the Mensana Clinic Pain Validity Test, putting her in the
Exaggerating Pain Patient category. A trial with an Amytal (truth serum) interview
failed to resolved the scoliosis, but when the patient was anesthetized, the
scoliosis resolved temporarily. Further Amytal interviews revealed the patient
had a stormy marital relationship, and she avoided sex with her husband,
because he was abusive. The patient was reassured she need not have sex with
her husband if he was abusive. The next day, she walked upright, and continued
in this posture, until her husband visited. The day of the visit, the scoliosis
returned. 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 social
worker intervention, she found the support to do so. The scoliosis resolved. On
five 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 Amobarbital
Narcosynthesis, The Clinical Journal of Pain, 2:179-182, 1987).

10. Mixed Objective-Exaggerating
Pain Patient
The patient was a 33 year old white female, married for the third time. She had a
gradual onset of lower neck and right arm pain. She complained of “excruciating
pain,” “devastating pain,” and “unbearable pain.” She arrived for her first interview
wearing 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. She
used superlatives for everything. Despite her clear histrionic personality disorder,
she scored 20 on the Mensana Clinic Pain Validity Test, placing her in the Mixed
Exaggerating-Objective pain patient category. Her MMPI scores showed elevated
scales 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 creature
comfort, from the finest cars, to a maid. She clearly was overusing her narcotic
medication. Her pain was made worse with extension of her neck, and she
subsequently 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, she
was 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).

11. 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

12. Minnesota Multiphasic
Personality 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

13. 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

14. MMPI of “low back losers”
• Pilling, Bleumer, and Sternback, based on their
misunderstanding of pain and the MMPI,
labeled patients “Pain prone patient,” “pain
neurosis,” and “low back loser.”
• They based this on the elevated scales of 1
and 3 (hysteria and hypochondriasis), of the
MMPI, and the absence of the elevation of
scale 2 (depression).
• This formed the so called “Conversion V”
because the graph of the scales has a V in it.

15. MMPI flaws
• The theory states that the MMPI doesn’t
change over time, since it measure personality
characteristics, or personality traits
• Researcher claim the MMPI can tell if a patient
is faking their pain or not, based on MMPI
score
• This is an erroneous statement, since the
MMPI in the same person who have chronic
pain, will change as the depression changes,
giving a
“Conversion V” in the early and late stages, and

16. Graphic MMPI scores

17. Gordon, R. M. (2001). MMPI/MMPI-2 Changes in Long-Term Psychoanalytic Psychotherapy.
Issues in Psychoanalytic Psychology, 23,(1 and 2),
Research by Gordon clearly illustrates
that the MMPI does change over time

18. 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.

19. 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)

20. Longitudinal Studies on Depression
Patients 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)

21. 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.

22. 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.

23. 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.

24. Overused Psychiatric Diagnoses in
Chronic Pain Patients
1) The incidence of hysterical conversion
reaction is small in a general psychiatric
population (1%-2% of admissions).
2)The incidence of hysterical conversion in a
chronic pain population that is properly
diagnosed, is even smaller (3/6000 or .05%).
3) Even after diagnosed with conversion
reaction, there is less than a 10% chance the
patient really has this, and most likely has
medical disease.

25. 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.

26. 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.

27. 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.

28. Suicide and Pain
Chronic 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

29. 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.

30. 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 patient's depression.

31. 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 patient's
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

32. 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

33. 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

34. 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

35. 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

36. 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, 8-25
represent 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 Patient
1
11/13 = 85%
0
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

37. 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

38. 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