The Power Point outlines the many attempts to explain the co-existence of chronic pain and psychological issues. It list various psychological tests used to assess chronic pain, and compares them.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
This is a detailed lecture on introduction to pain management for EMS providers. It was originally written for the new AEMT class, but would serve as a start for any medic class as well. NOTE: It does not include drug doses for opioids and benxo's, as this was written for AEMT, but that would be an easy fix for any Medic Program. Estimated time for delivary 2 hours.
plain for treatment of patient with chronic pain, psychiatry and psychology are two approaches very important to have a proper treatment for pain disorders
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
This is a detailed lecture on introduction to pain management for EMS providers. It was originally written for the new AEMT class, but would serve as a start for any medic class as well. NOTE: It does not include drug doses for opioids and benxo's, as this was written for AEMT, but that would be an easy fix for any Medic Program. Estimated time for delivary 2 hours.
plain for treatment of patient with chronic pain, psychiatry and psychology are two approaches very important to have a proper treatment for pain disorders
definition of pain - classification - categories and different clinical types of pain - assessment of pain and how to manage using pharmacological and non-pharmacological intervention
The presentation enhances the reader to get comprehensive view about Pain ( physiology of pain, assessment of pain and Management of pain). This will help you to management pain effectively.
New directions in the psychology of chronic pain managementepicyclops
Lecture followed audience discussion on contextual cognitive behaviour therapy and acceptance and commitment therapy in the management of chronic pain from the West of Scotland Pain Group on Wednesday 5th December 2007. The speaker is Lance M. McCracken PhD, of the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases & University of Bath, Bath UK.
www.wspg.org.uk
Further reading:
DAHL, J., & LUNDGREN, T. (2006). Living beyond your pain using acceptance and commitment therapy to ease chronic pain. Oakland, CA, New Harbinger Publications.
http://www.worldcat.org/oclc/63472470
HAYES, S. C., STROSAHL, K., & WILSON, K. G. (1999). Acceptance and commitment therapy an experiential approach to behavior change. New York, Guilford Press.
http://www.worldcat.org/oclc/41712470
MCCRACKEN, L. M. (2005). Contextual cognitive-behavioral therapy for chronic pain. Progress in pain research and management, v. 33. Seattle, IASP Press.
http://www.worldcat.org/oclc/57564664
definition of pain - classification - categories and different clinical types of pain - assessment of pain and how to manage using pharmacological and non-pharmacological intervention
The presentation enhances the reader to get comprehensive view about Pain ( physiology of pain, assessment of pain and Management of pain). This will help you to management pain effectively.
New directions in the psychology of chronic pain managementepicyclops
Lecture followed audience discussion on contextual cognitive behaviour therapy and acceptance and commitment therapy in the management of chronic pain from the West of Scotland Pain Group on Wednesday 5th December 2007. The speaker is Lance M. McCracken PhD, of the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases & University of Bath, Bath UK.
www.wspg.org.uk
Further reading:
DAHL, J., & LUNDGREN, T. (2006). Living beyond your pain using acceptance and commitment therapy to ease chronic pain. Oakland, CA, New Harbinger Publications.
http://www.worldcat.org/oclc/63472470
HAYES, S. C., STROSAHL, K., & WILSON, K. G. (1999). Acceptance and commitment therapy an experiential approach to behavior change. New York, Guilford Press.
http://www.worldcat.org/oclc/41712470
MCCRACKEN, L. M. (2005). Contextual cognitive-behavioral therapy for chronic pain. Progress in pain research and management, v. 33. Seattle, IASP Press.
http://www.worldcat.org/oclc/57564664
Current methods of fraud detection used by insurance companies are not cost effective. This presentation describes the inaccuracy of the MMPI, and presents a new test, which can predict who will had medical test abnormalites with 95% accuracy, and who wil not have medical test abnormalities with 85% accuracy (the fakers). Available in English and Spanish at www.MarylandClinicalDiagnostics.com
Current methods of fraud detection used by insurance companies are not cost effective. This presentation describes the inaccuracy of the MMPI, and presents a new test, which can predict who will had medical test abnormalites with 95% accuracy, and who wil not have medical test abnormalities with 85% accuracy (the fakers). Available in English and Spanish at www.MarylandClinicalDiagnostics.com
The Power Point reviews various methods used for fraud detection, and points out that many are erroneous or not cost effective. It offers information about an Internet test which has been admitted as evidence in many court cases in many states
Malingering accounts for millions of dollars lost in the workplace. This chapter, from the past president of the American Academy of Pain Management, and former Johns Hopkins Hospital staff member, appeared in a book edited by Dr. Kathy Foley from Cornell. It tells an attorney or insurance adjuster how to spot a malingerer or a faker, and how this differs from other disorders. It also recommends an Internet test at www.MarylandClinicalDiagnostics.com, which can identify malingerers with 85% to 95% accuracy and can be used in court.
This chapter establishes the differential diagnosis between patients who are faking and malingering versus patients who are misdiagnosed, and mistakenly thought to be malingering because they are not getting well. Psychological myths about conversion are dispelled.
Psychogenic Pain : Psychosomatic Point of ViewAndri Andri
This presentation was presented in "Medical Approach in Holistic Management to Relieve Pain" 13 Des 2015 at The Sunan Hotel, SOLO.
Since Pain is always subjective, Psychogenic pain is very related to psychiatric problems and very often it does not recognized by physicians in their practice.
The paper lists the correct method of diagnosing chronic pain, and matching the proper medication to tissue damage without the use of narcotics or opioids.
This chapter describes the normal psychological response to pain, over time. The stages mimic the psucholoigcal response described by Kubler-Ross in her book on death and dying. Hendler documents that it is normal to get depressed from chronic pain, usually by the 6th month, and this depression can last 3-8 years.
Ethics of Pain Care: what duties do we have to patients with chronic pain?Mark Sullivan
In this presentation, I ask: what duties do we have to patients with chronic pain? I examine the case of Daniel, a 48-year-old man with chronic back, neck and head pain after a motor vehicle accident 8 years previously. I argue that our foremost duty to patients with chronic pain is not to reduce their pain intensity but to improve their health. Titrating opioid doses to a pain level may reduce pain and at the same time make it harder for a patient to live his or her life.
The Power Point reviews
various methods used for detecting malingering,
and points out that many are erroneous or not cost effective.
It offers information about an accurate and cost effective Internet test used to detect malingering, which has been
admitted as evidence in many court cases in many states
Third Party Reporting of Patient Improvement.docxNelson Hendler
Reproting of outcome studies is often subjective. This collection of real leterrs, emails, and Facebook posting provides third party documentation and validation of the efficacy of treatment, without the subjective bias of the party doing the treatment.
Johns Hopkins Hospital doctors report that 40%-80% of chronic pain patient are misdiagnosed, and that MRIs and CTs miss pathology 56%-78% of the time, Therefore, during extensive chart reviews of current medical data will produce a classic case of GIGO-garbage in giving garbage out. The need for accurate diagnoses and testing is critical for AI to work.
Top_Down_or_The_Bottom_Up to Save Money.pdfNelson Hendler
The article describes the need for a more "granular:" assessment of workers' compensation claims, rather than the typical approach of insurance carriers which average large numbers, which causes the loss of valuable data.
The former head of HR for Burger King, British Petroleum, and Walmart, and former Assist. Prof. of Neurosurgery from Johns Hopkins Hospital describe methods to save 54% on workers' compensation using on-line "expert system" questionnaire from Johns Hopkins Hospital doctors
40%-80% of auto accident claimants have overlooked diagnoses. The most commonly overlooked are thoracic outlet syndrome, cervical disc damage mistakenly called sprain or whiplash, post-concussion syndrome, slipping rib syndrome, Tietze syndrome and Tempro-mandibular joint syndrome. This article tells readers the clinical sign and symptoms of each and the correct medical tests to use, which are employed by doctors at Johns Hopkins Hospital. It also described an on-line questionnaire at www.DiagnoseThePains.com which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors.
This paper shows how thermography can be used to disprove the misdiagnosis and over used diagnosis of "psychogenic pain." in a group of chronic pain patients.
This article outlines the differences between the anatomical and pharmacological differences between acute and chronic pain. This has significant implications for treatment, since they really are separate disorders.
This study compares the effect of benzodiazepines to narcotics on EEG, memory quotient, and WAIS testing. Valium, Librium, Dalmane and other benzodiazepines produced EEG and cognitive abnormalities in 70% of the patients, while only 30% of patients on narcotics had cognitive impairment.and EEG abnormalities.
Bi-polar patients who were having side-effects from lithium were given spironolactone to control mood swings. Five the 6 had good control for 1 year. The mechanism of membrane stabilization compared to lithium are discussed.
Emg vs. thermography to diagnose crps and radiculopthyNelson Hendler
This large clinical trial (803) patients compares the accuracy of thermography to EMG studies to see which one was a better diagnostic tool for each disorder and the degree of overlap between testing.
Valuable info for orthopedic and neurosurgeons specializing in spinal injuriesNelson Hendler
Reports from Johns Hopkins Hospital doctors document that 40%-80% of patients labeled as soft tissue injury, whiplash, sprain or strain are misdiagnosed. Use of an Internet expert system provides diagnoses with a 96% correlation with diagnoses of former Johns Hopkins Hospital doctors, resulting in a 192% increase in interventional testing, and a 50%-63% increase in surgery in previously misdiagnosed patients, 93% of whom report good to excellent improvement after surgery. .
Headache diagnostc paradigm from former Johns Hopkins Hospital staffNelson Hendler
The medical literature reports that 35%-70% of patients diagnosed with migraine headache do not have this order. The Internet based "expert system" developed by former Johns Hopkins Hospital staff, including the past president of the American Headache Society and American Academy of Pain Management provides an Internet based "expert system" which gives diagnoses with a 94% correlation with diagnosed of these doctors.
Missed Diagnoses association in Rear end collisions Nelson Hendler
There are a number of overlooked diagnoses which occur after a rear-end accident. This paper shows an attorney how to convert a misdiagnosed 'soft tissue injury case" into damaged cervical disc,TMJ, thoracic outlet syndrome,and post concussion syndrome using a diagnostic paradigm to get diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This improves patient care and increases recovery.
This list is all of the researchers who have published articles on the Pain Validity Test and Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com
This is a simplified instruction manual, with screen shots, which will teach staff members how to administer the on-line questionnaires from www.MarylandClinicalDiagnostics.com. It will take any staff member only 15 minutes to review the handbook. Once they have reviewed the handbook, it will take only 5 minutes of staff time to set up a patient to take the tests from www.MarylandClinicalDiagnostics.com
Three Dimensional CT Imaging in post-surgical "failed back" syndromeNelson Hendler
A team of physicians from Johns Hopkins Hospital document that a regular CT misses pathology 56% of the time compared to a 3D-CT. However, if the patient has had previous surgery, the CT misses pathology 76% of the time compared to a 3D-CT. The 3D-CT can be used to combat misdiagnosis of "psychogenic pain patients."
Unveiling the Secrets How Does Generative AI Work.pdfSam H
At its core, generative artificial intelligence relies on the concept of generative models, which serve as engines that churn out entirely new data resembling their training data. It is like a sculptor who has studied so many forms found in nature and then uses this knowledge to create sculptures from his imagination that have never been seen before anywhere else. If taken to cyberspace, gans work almost the same way.
Memorandum Of Association Constitution of Company.pptseri bangash
www.seribangash.com
A Memorandum of Association (MOA) is a legal document that outlines the fundamental principles and objectives upon which a company operates. It serves as the company's charter or constitution and defines the scope of its activities. Here's a detailed note on the MOA:
Contents of Memorandum of Association:
Name Clause: This clause states the name of the company, which should end with words like "Limited" or "Ltd." for a public limited company and "Private Limited" or "Pvt. Ltd." for a private limited company.
https://seribangash.com/article-of-association-is-legal-doc-of-company/
Registered Office Clause: It specifies the location where the company's registered office is situated. This office is where all official communications and notices are sent.
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Liability Clause: It outlines the extent of liability of the company's members. In the case of companies limited by shares, the liability of members is limited to the amount unpaid on their shares. For companies limited by guarantee, members' liability is limited to the amount they undertake to contribute if the company is wound up.
https://seribangash.com/promotors-is-person-conceived-formation-company/
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Legal Requirement: The MOA is a legal requirement for the formation of a company. It must be filed with the Registrar of Companies during the incorporation process.
Constitutional Document: It serves as the company's constitutional document, defining its scope, powers, and limitations.
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External Communication: It provides clarity to external parties, such as investors, creditors, and regulatory authorities, regarding the company's objectives and powers.
https://seribangash.com/difference-public-and-private-company-law/
Binding Authority: The company and its members are bound by the provisions of the MOA. Any action taken beyond its scope may be considered ultra vires (beyond the powers) of the company and therefore void.
Amendment of MOA:
While the MOA lays down the company's fundamental principles, it is not entirely immutable. It can be amended, but only under specific circumstances and in compliance with legal procedures. Amendments typically require shareholder
RMD24 | Debunking the non-endemic revenue myth Marvin Vacquier Droop | First ...BBPMedia1
Marvin neemt je in deze presentatie mee in de voordelen van non-endemic advertising op retail media netwerken. Hij brengt ook de uitdagingen in beeld die de markt op dit moment heeft op het gebied van retail media voor niet-leveranciers.
Retail media wordt gezien als het nieuwe advertising-medium en ook mediabureaus richten massaal retail media-afdelingen op. Merken die niet in de betreffende winkel liggen staan ook nog niet in de rij om op de retail media netwerken te adverteren. Marvin belicht de uitdagingen die er zijn om echt aansluiting te vinden op die markt van non-endemic advertising.
Improving profitability for small businessBen Wann
In this comprehensive presentation, we will explore strategies and practical tips for enhancing profitability in small businesses. Tailored to meet the unique challenges faced by small enterprises, this session covers various aspects that directly impact the bottom line. Attendees will learn how to optimize operational efficiency, manage expenses, and increase revenue through innovative marketing and customer engagement techniques.
Tata Group Dials Taiwan for Its Chipmaking Ambition in Gujarat’s DholeraAvirahi City Dholera
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VAT Registration Outlined In UAE: Benefits and Requirementsuae taxgpt
Vat Registration is a legal obligation for businesses meeting the threshold requirement, helping companies avoid fines and ramifications. Contact now!
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Affordable Stationery Printing Services in Jaipur | Navpack n PrintNavpack & Print
Looking for professional printing services in Jaipur? Navpack n Print offers high-quality and affordable stationery printing for all your business needs. Stand out with custom stationery designs and fast turnaround times. Contact us today for a quote!
3.0 Project 2_ Developing My Brand Identity Kit.pptxtanyjahb
A personal brand exploration presentation summarizes an individual's unique qualities and goals, covering strengths, values, passions, and target audience. It helps individuals understand what makes them stand out, their desired image, and how they aim to achieve it.
"𝑩𝑬𝑮𝑼𝑵 𝑾𝑰𝑻𝑯 𝑻𝑱 𝑰𝑺 𝑯𝑨𝑳𝑭 𝑫𝑶𝑵𝑬"
𝐓𝐉 𝐂𝐨𝐦𝐬 (𝐓𝐉 𝐂𝐨𝐦𝐦𝐮𝐧𝐢𝐜𝐚𝐭𝐢𝐨𝐧𝐬) is a professional event agency that includes experts in the event-organizing market in Vietnam, Korea, and ASEAN countries. We provide unlimited types of events from Music concerts, Fan meetings, and Culture festivals to Corporate events, Internal company events, Golf tournaments, MICE events, and Exhibitions.
𝐓𝐉 𝐂𝐨𝐦𝐬 provides unlimited package services including such as Event organizing, Event planning, Event production, Manpower, PR marketing, Design 2D/3D, VIP protocols, Interpreter agency, etc.
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⭐ 𝐅𝐞𝐚𝐭𝐮𝐫𝐞𝐝 𝐩𝐫𝐨𝐣𝐞𝐜𝐭𝐬:
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Personal Brand Statement:
As an Army veteran dedicated to lifelong learning, I bring a disciplined, strategic mindset to my pursuits. I am constantly expanding my knowledge to innovate and lead effectively. My journey is driven by a commitment to excellence, and to make a meaningful impact in the world.
The effects of customers service quality and online reviews on customer loyal...
Course 5 psychological aspects of 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. 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.
15. 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)
16. 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)
17. 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.
18. 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.
19. 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.
20. 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.
21. 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.
22. 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.
23. 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.
24. 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
25. 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.
26. 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.
27. 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
28. 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
29. 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
30. 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
31. 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
32. 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
33. 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
34. 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