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BIBLIOGRAPHY

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I . Brody DS, Hahn SR, Spitzer RL, et al: Identifying patients with depression in the primary care setting: A more efficient method. Arch Intern Med 158(22):2469-2975, 1998. 2. Katon WJ, Walker EA: Medically unexplained symptoms in primary care. J Clin Psychiatry 59 Suppl 20:15-21, 1998. 3. Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States: Results from the National Comorhidity Survey. Arch Gen Psychiatry 5 1:8-19, 1994. 4. Kessler LG, Cleaty PD, Burke JD: Psychiatric disorders in primary care. Arch Gen Psychiahy 42583-587, 1985. 5. Lustman PJ: Anxiety disorders in adults with diabetes mellitus. Psychiatr Clin North Am 11(2):419-431, 1988. 6. Von Korff M, Shapiro S, Burke JD: Anxiety and depression in a primary care clinic. Arch Gen Psychiatry 44152-156, 1987. I . Walker EA, Katon WJ, Jemelka RP: Psychiatric disorders and medical care utilization among people in the general population who report fatigue. J Gen Intern Med 8:436-440, 1993. 8. Yingling KW, Wulsin LR, Arnold LM, Rouan GW: Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain. J Gen Intern Med 8:231-235, 1993.

69. THE MANAGEMENT OF CHRONIC PAIN

Ro6evt N.Jamison, Ph.D.
1. What is the difference between acute and chronic pain? Acute pain generally is associated with tissue damage and represents a warning of injury to the individual. It is expected to be directly proportional to the sensory input of the tissue damage and to continue until the damaged tissue and/or afferent pathways have returned to normal functioning. Chronic noncancer pain, in contrast, is a persistent condition often associated with an initial episode of acute pain but continuing long past the time when healing would normally take place. Chronic noncancer pain serves no beneficial purpose and is resistant to medical intervention.

2. What are the different categories of pain?

Pain syndromes may be categorized according to the character and history of the symptom: Acute pain is self-limiting, usually of less than 6-month duration, and generally adaptive in nature (e.g., postsurgical pain, dental pain, pain following injury). Recurrent acute pain consists of a series of intermittent episodes of pain that are acute in character but chronic insofar as the condition persists for more than 6 months (e.g., migraine headaches, trigeminal neuralgia, temporomandibular disorder). Chronic nonmalignant pain persists beyond 6 months and is intractable. Pain severity varies over time and may or may not have a known relationship to active pathophysiologic or pathoanatomic process (e.g., chronic mechanical low back pain, diffuse myofascial pain syndrome). Chronic progressive pain increases in severity over time and often is associated with malignancies and degenerative disorders (e.g., skeletal metastatic disease, rheumatoid arthritis).

3. How do psychogenic and organic pain differ?

Chronic pain represents a complex interaction of factors. The pain typically is related to an initial somatic event but, over time, is increasingly influenced by the patients personality, beliefs, and environment. Attempts to reliably distinguish between organic and psychogenic pain have been largely unsuccessful. Many practitioners incorrectly believe that chronic pain reflects either organic pathology or psychogenic symptoms. If physical findings are inadequate

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to account for a patients report of chronic pain, then the pain often is perceived to be mostly psychological. It generally is unwarranted, however, to assume that psychological factors are the primary cause of pain.

4. Which measures are useful in assessing pain intensity? Pain intensity can be measured by subjective numerical pain ratings (scales from 0-10 or 0-loo), visual analogue scales, verbal rating scales, pain drawings, and combined standardized questionnaires. 5. What is a visual analogue scale? A popular means of measuring pain intensity is the visual analogue scale (VAS), which uses a straight line, usually 10 cm long, with the extreme limits of pain on either end of the line. The patient is instructed to place a mark on the line to best indicate pain severity. Scores are obtained by measuring the distance from the end labeled no pain to the mark made by the patient. Although frequently used to measure chronic pain, the VAS is time-consuming to score and has questionable validity for older patients.

6. What are verbal ratings of pain? A verbal pain-rating scale consists of 4-15 words that are ranked according to expression of
pain (from no pain to excruciating pain). The patient chooses the words that best describe the pain. Verbal scales not only measure pain intensity but also assess sensory and affective dimensions of the pain experience. Verbal scales also can be used to measure pain description. The patient chooses words from a list of words, such as piercing, stabbing, shooting, burning, and throbbing, that best describe the pain experience.
7. What is the McGill Pain Questionnaire? The McGill Pain Questionnaire (MPQ) is a popular, comprehensive questionnaire that includes 20 subclasses of descriptors as well as a numerical pain-intensity scale and a dermatomal pain drawing. It is a frequently employed clinical tool in the subjective measurement of pain. A short form also is popular. The MPQ allows for measurement of different aspects of the pain experience and is sensitive to treatment effects and the differential diagnosis.

8. What tools best evaluate psychopathology in chronic pain patients?

There is ongoing debate among mental health professionals about the best ways to measure psychopathology in chronic pain patients. Most chronic pain patients do not have a history of premorbid psychiatric disturbance, but show reactive emotional distress in response to their pain. However, when present, major psychopathology is indicative of a poor prognosis for pain therapy. Pain patients frequently endorse somatic complaints in response to their condition. Thus, caution is necessary in interpreting psychological tests in which somatic complaints are considered indicative of psychopathology in pain patients. The measures most commonly used to evaluate psychopathology and emotional distress in chronic pain patients include the Minnesota Multiphasic Personality Inventory (MMPI), the Symptom Checklist 90 (SCL-90-R), the Millon Behavior Health Inventory (MBHI), the Illness Behavior Questionnaire (IBQ), and the Beck Depression Inventory (BDI). Assessment Categories and Frequently Used Psychometric Measures
PSYCHOSOCIAL HISTORY

CAGE Questionnaire Comprehensive Pain Questionnaire Michigan Alcoholism Screening Test (MAST) Self-Administered Alcoholism Screening Test (SAAST) Structured Clinical Interview for DSM-IV (SCID)
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Assessment Categories and Frequently Used Psychometric Measures (Cont.)
PAIN INTENSITY

39 1

Numerical rating scales Pain drawings Verbal rating scales (VRS) Visual analog scales (VAS)
MOOD AND PERSONALITY

Beck Depression Inventory (BDI) Center for Epidemiologic Studies Depression Scale (CES-D) Illness Behavior Questionnaire (IBQ) Millon Behavior Health Inventory (MBHI) Minnesota Multiphasic Personality Inventory (MMPI-2) Symptom Checklist 90-R (SCL-90)
PAIN BELIEFS AND COPING

Coping Strategies Questionnaire (CSQ) Inventory of Negative Thoughts in Response to Pain (INTRP) Pain Management Inventory (PMI) Pain Self-EfficacyQuestionnaire (PSEQ) Survey of Pain Attitudes (SOPA)
FUNCTIONAL CAPACITY

MultidimensionalPain Inventory (MPI) Oswestry Disability Questionnaire (ODQ) Pain Disability Index (PDI) Short-Form Health Survey (SF-36) Sickness Impact Profile (SIP)

9. How is the MMPI used in assessing chronic pain patients? The MMPI, which consists of 561 true-or-false items, produces distinct profiles of pain patients. Studies have shown that profile patterns allow prediction of return to work and response to surgical treatment in males. A revised version, MMPI-2, replicates the profile patterns of the original MMPI. Again, despite this tests popularity in measuring the presence of psychopathology, remember that profiles of chronic pain patients can be misinterpreted because these patients frequently endorse physical symptoms.

10. Describe the Beck Depression Inventory. The BDI is a 2l-item, self-report questionnaire that provides a measure of severity of depression. It is commonly used to assess depressive symptomatology in chronic pain patients and determine treatment outcome. It is easy to administer and score.

11. What other tools are valuable in assessing depression? Other valuable measures include the Center for Epidemiologic Studies Depression Scale and the Hamilton and the Zung Depression Scales. Regardless of the tool used, a shared limitation is the possible misinterpretation of an elevated score: chronic pain patients frequently report fatigue, sleep disturbances, and loss of sexual interest, which can be interpreted as signs of clinical depression.
12. Describe the SCL-90-R, the MBHI, and the IBQ. The SCL-90-R is a 90-item checklist that uses a five-point scale. It offers a global index score as well as nine subscale scores to provide a general assessment of emotional distress. The SCL-90-R is a relatively brief measure and offers some validity for pain patients (the items make sense to them). It is easy to inspect individual items that may pertain specifically to persons with chronic pain. The disadvantages of this measure are that all subscales are highly correlated and there are no validity scales to determine the presence of subtle inconsistencies in responses.

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The MBHI contains 150 true-or-false items to assess mood and personality, and offers 20 subscales that measure styles relating to providers, psychosocial stressors, and response to illness. The advantage of the MBHl is that the scales are not subject to misinterpretation due to physical symptoms. Unlike the other measures, the MBHI emphasizes medical rather than emotional concerns. The IBQ determines emotionality and illness behavior in chronic pain patients. It contains 62 true-or-false items and comprises seven subscales measuring symptom complaints and abnormal illness behavior. Patients who are not known to have organic pathology that would account for their pain tend to produce higher IBQ scores. The IBQ also is correlated with anxiety measures.

13. How are pain-related beliefs measured?

A persons beliefs about pain are important in predicting the outcome of treatment. Negative thoughts about an ongoing pain problem may contribute to increased pain and emotional distress, decreased functioning, and greater reliance on medication. Certain chronic pain patients are prone to maladaptive beliefs about their condition that may not be compatible with its physical nature (e.g., This pain will make me lose my mind. Soon I will become an invalid.). The tests most frequently used to measure maladaptive beliefs include the Coping Strategies Questionnaire, the Pain Management Inventory, the Pain Self-Efficacy Questionnaire, the Survey of Pain Attitudes, and the Inventory of Negative Thoughts in Response to Pain.

14. What are the best ways to measure functional capacity? The assessment of functional capacity and interference with activity is important since thirdparty payers frequently judge treatment outcome as successful on the basis of improved function and return to work. Reliable instruments for measuring function include the Sickness Impact Profile, the Short-Form Health Survey, the Multidimensional Pain Inventory, the Pain Disability Index, and the Oswestry Disability Questionnaire. Other functional measures, which are not as popular, include The Chronic Illness Problem Inventory, The Waddell Disability Instrument, and The Functional Rating Scale. Automated devices such as the portable up-time calculator and the pedometer are useful ways to obtain accurate measures of activity. These devices should be used in conjunction with self-monitoring assessment techniques. 15. List the options for treating chronic pain. Hot and cold packs Massage therapy Physical therapy Didactic instruction Relaxation training Hypnosis Biofeedback

Psychotherapy Acupuncture Medication Nerve block therapy Implantable devices Surgical treatments

16. What is an interdisciplinary pain treatment program? Chronic pain involves a complex interaction of physiological and psychosocial factors, and successful intervention requires the coordinated effort of a treatment team with expertise in a variety of therapeutic disciplines. Although some pain centers offer a unimodal treatment approach, most programs blend medical, psychological, vocational, and educational techniques. The interdisciplinary core staff typically includes one or more physicians, a clinical psychologist, and a physical therapist. Other health professionals who may play important roles include clinical nurse specialists, occupational therapists, vocational rehabilitation counselors, and acupuncturists.

17. How are outpatient pain programs typically structured? Multidisciplinary pain programs administered on an outpatient basis often are highly structured, time limited, and organized along a specific treatment schedule. The patient is expected to attend clinic sessions and to participate actively in all aspects of the program. These expectations must be made clear.

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To this end, patients frequently sign a treatment contract that spells out the general program requirements as well as individual treatment goals. In addition to helping patients understand exactly what is expected of them, such a contract provides a mechanism for identifying those patients who, prior to treatment, lack motivation or may have difficulty conforming to the structure of the program. Patients are asked to keep a daily written record of their pain intensity, medication use, and activity levels.

18. What are the desired outcomes of interdisciplinarytreatment?

The therapeutic aims of interdisciplinary interventions for chronic noncancer pain include decreased pain intensity, increased physical activity, decreased reliance on pain medication, a return to work, improved psychosocial functioning, and reduced use of healthcare services.

19. List the main objectives of cognitivehehavioraltherapy for chronic pain patients. Help patients view their problem as manageable, instead of overwhelming. Patients who are prone to catastrophize benefit from examining the way they view their situation. What could be perceived as a hopeless condition can be reframed as a difficult yet manageable condition over which they can exercise some control. Help convince patients that the treatment is relevant to their problem and that they need to be actively involved in their treatment and rehabilitation. Teach patients to monitor maladaptive thoughts and substitute positive thoughts. Persons with chronic pain are plagued, either consciously or unconsciously, by negative thoughts related to their condition. These negative thoughts perpetuate pain behaviors and feelings of hopelessness. Adaptive management techniques for chronic pain are an important component of cognitive restructuring. 20. What is the role of group therapy for pain patients? Pain patients frequently show signs of emotional distress, with evidence of depression, anxiety, and imtability. Group therapy with a cognitivehehavioral orientation is designed to help patients gain control of the emotional reactions associated with chronic pain. Specific problem-solving strategies can be offered, including: identifying maladaptive and negative thoughts, disrupting irrational thinking, constructing and repeating positive self-statements, learning distraction techniques, working to prevent future catastrophizing, and examining ways to increase social support. In addition, group therapy presents an opportunity to discuss any concerns or problems that patients may have in common.

21. How important is family involvement in therapy?

Chronic pain significantly impacts all members of a family. Family members need to be educated about the goals of therapy and should have an opportunity to share their worries and concerns. Moreover, active involvement of family members helps ensure the patients long-term success. Therefore, both patients and members of their families should be invited to attend family therapy sessions. Besides enhanced communication, important outcomes of these sessions are that family members learn how to help the patient achieve and maintain goals, and they come to understand that they are not alone in their dealings with the person in pain.

22. What are the benefits of relaxation training for chronic pain patients? Chronic pain patients tend to experience substantial residual muscle tension as a function of the bracing, posturing, and emotional arousal often associated with pain. Such responses, maintained over a long period, can exacerbate pain in injured areas of the body and increase muscular discomfort. For example, patients with low back pain or limb injuries commonly experience neck stiffness and tension-type headaches. Relaxation training can lead to pain reduction by relaxing tense muscle groups, reducing anxiety, distracting the patient from the pain, and enhancing self-efficacy. In addition, this training can increase the patients sense of control over physiological responses. In a pain management program, patients are taught and encouraged to practice a variety of relaxation strategies, including diaphragmatic breathing, progressive muscle relaxation, autogenic relaxation, guided imagery, and cue-controlled relaxation. Hypnosis and biofeedback training also are commonly employed.

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23. Which variables predict a low probability of return to work? The most relevant predictor of return to work is the duration of unemployment. After 6 months of unemployment due to chronic pain, the probability of return of work is 50%; the likelihood decreases to 10% after 1 year. Other factors negatively impacting the likelihood of return to work include limited formal education, limited transferable skills, poor perceived social support, ongoing litigation, a poor relationship with the employer, and job dissatisfaction.

24. How can vocational rehabilitation help chronic pain patients? The goal of vocational rehabilitation is to return a patient with chronic pain to work. After an extended period out of work, patients become both physically and psychologically deconditioned to the demands and stresses of the workplace. A vocational rehabilitation counselor helps the patient develop a plan that incorporates long-range employment goals and short-term objectives based on medical, psychological, social, and vocational information. These counselors are specialists in the assessment of aptitudes and interests, transferable skills, physical capacity, modifications in the workplace, skills training, and job readiness. 25. What is the role of activity and exercise for persons with chronic pain? Most patients lose physical stamina and flexibility because of reluctance to exercise and a perceived need to protect themselves from additional physical injury. Some patients have been medically advised to restrict activity when pain increases. Patients with chronic pain need to know that exercise is important. Getting back to usual activities as soon as possible after an injury helps to prevent disability. Some stretching, cardiovascular activity, and weight training should be considered.

26. Under what circumstances should opioid therapy be prescribed? The use of opioid analgesics for chronic noncancer pain is controversial, due to concerns about efficacy, adverse effects, tolerance, and addiction. Opioid therapy is contraindicated by a history of substance abuse, a major psychiatric diagnosis, the seeking of drugs from multiple physicians, uncontrolled dose escalation, and/or evidence of lack of compliance. Patients with significant adverse reactions to low-dose opioid therapy also are poor candidates. The decision to use opioid therapy often rests on clinical judgment and treatment orientation.
27. What are the roles of invasive procedures and implantable devices in pain management? There are many types of invasive interventions for pain. They range from trigger point injections to spinal cord stimulation and deep brain surgery. Patients are attracted to any treatment that is designed to decrease their pain. However, careful assessment and evaluation of the patients prior to the procedures, including a thorough psychological evaluation, helps to identify those patients who are poor candidates and improves the chances for a positive outcome. Many insurance camers require a comprehensive psychological evaluation prior to approval of an implantable device for pain. 28. How can relapse be avoided? Most chronic pain patients need support after completing a pain treatment program, to maintain the gains they have achieved. Patients should be encouraged to identify and anticipate situations that place them at risk for returning to previous maladaptive behavior patterns. They also should be encouraged to rehearse problem-solving techniques and behavioral responses that enable them to avoid a relapse. The goals of relapse prevention are to help the patient ( 1 ) maintain a steady level of activity, emotional stability, and appropriate medication use; (2) anticipate and deal with situations that cause setbacks; and (3) acquire skills that decrease reliance on the healthcare system. Followup has been shown to be vital in helping to prevent relapse. A specific followup plan should be written out for each patient.

29. What criteria are important in the evaluation of a pain treatment program? An important component of any group-based pain program is its ability to measure its own effectiveness and determine which services are most beneficial in the treatment of chronic pain patients. A number of recommendations for effective program evaluation have been put forward by the Commission on the Accreditation of Rehabilitation Fac

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A system should be in place for obtaining followup information from patients on the use of medications, use of healthcare services, return to gainful employment, functional activities, ability to manage pain, and subjective pain intensity. Provisions should also be made for periodic contact after discharge. Program evaluation should encompass goals and objectives that are achievable and end results that are measurable. A program evaluation report should include primary objectives, measures, time of measurement, source of information, and expectancies as well as outcome.
BIBLIOGRAPHY

I . Accident Rehabilitation and Compensation Insurance Corporation and the National Health Committee: New Zealand Acute Low Back Pain Guide. Wellington, New Zealand, AAC and NHC, 1997. 2. American Academy of Pain Medicine and American Pain Society Consensus Statement: The use of opioids for the treatment of chronic pain. Pain Forum 6:77-79, 1997. 3. Cicala RS, Wright H: Outpatient treatment of patients with chronic pain: An analysis of cost savings. Clin J Pain 5:223-226, 1989. 4. Commission on the Accreditation of Rehabilitation Facilities: Standards Manual for Organizations Servicing People with Disabilities, Tucson, Arizona, CARF, 1999. 5. Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS: Chronic pain-associated depression: Antecedent or consequence of chronic pain? A review. Clin J Pain 13: 116-137, 1997. 6. Follick MJ, Ahern DK, Aberger EW: Behavioral treatment of chronic pain. In Blumenthal JA, McKee DC (eds): Applications in Behavioral Medicine and Health Psychology: A Clinicians Source Book. Sarasota, Florida, Professional Resource Exchange, Inc., 1987, pp 237-270. 7. Fordyce WE (ed): Back Pain in the Workplace: Management of Disability in Nonspecific Conditions. Seattle, International Association for the Study of Pain Press, 1995. 8. Gatchel RJ, Turk DC (eds): Psychological Approaches to Pain Management: A Practitioners Handbook. New York, The Guilford Press, 1996. 9. Jamison R N Learning to Master Your Chronic Pain. Sarasota, FL, Professional Resource Press, 1996. 10. Jamison RN: Mastering Chronic Pain: A Professionals Guide to Behavioral Treatment. Sarasota, FL, Professional Resource Press, 1996. 1 I . Karoly P, Jensen MP: Multimethod Assessment of Chronic Pain. New York, Pergamon Press, 1987. 12. Nigl AJ: Biofeedback and Behavioral Strategies in Pain Treatment. New York, Spectrum Publications, Inc., 1984. 13. Turk DC, Melzack R (eds): Handbook of Pain Assessment. New York, The Guilford Press, 1992.

70. THE ASSESSMENT AND TREATMENT OF SEXUAL DYSFUNCTION

Thomas D.Stewart, M.D
1. Can sexual dysfunction be a symptom of medical illness? Yes. Sexual dysfunction is a neglected vital sign in medical history taking. It can be the first presenting symptom for conditions as diverse as diabetes mellitus, temporal lobe epilepsy, multiple sclerosis, and thyroid dysfunction. 2. Describe a framework for the clinical evaluation of sexual dysfunction. Masters and Johnsons well-known sexual response cycle provides a paradigm for understanding and treating sexual dysfunction: Appetitive phase-involves noticing attractive people and having an intact libido. There are no specific physiologic responses. Excitement-is marked by vascular engorgement and lubrication in women and erection in men. These responses, associated with flushed skin, intensify and reach a plateau phase before orgasm.