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4MEDICAL REVIEW
Pain Assessment and the Mental Health Practitioner:
A Mind-Body Approach
Eliezer Schnall
Ferkauf Graduate School of Psychology
Albert Einstein College of Medicine
Bronx, New York 10461
ABSTRACT
ASSESSMENT OF PAIN
Pain is the most common reason individuals visit physicians, yet medical doctors are often inadequately trained
in pain assessment. Furthermore, pain is increasingly
viewed as having significant affective and cognitive
components necessitating a biopsychosocial approach.
The role of the mental health practitioner is essential in a
mind-body approach to pain assessment. In addition,
issues arising in special populations, such as children and
the elderly, require special attention.
The simplest way to assess pain is via patient self-report
scales. Admittedly, these instruments are inherently
subjective. Furthermore, they often require a patient to
recall, perhaps unreliably, the amount of pain the
patient suffered at various times, how much the patient
thought about the pain, and in what activities the
patient was involved. However, new palm-top computers
make it more convenient to complete reports throughout the day (Carpenter, 2002a), presumably adding to
their accuracy. Such devices may even “beep” to remind
the patient when he is to answer specific questions, and
are thus superior to traditional pain diaries. Of course,
the cost of this technology is sometimes prohibitive
(Keefe et al., 2001).
INTRODUCTION
More than 23 million surgical procedures are performed
each year in the United States in addition to the 50
million traumatic injuries, both of which usually cause
substantial pain. Moreover, 3.5 million Americans suffer
from cancer, a disease that often leads to chronic pain,
and as many as 50 million others suffer chronic pain
from a host of other causes. Not surprisingly, pain is the
most common reason individuals visit their physicians,
accounting for over 70 million visits per year (80%) in
the United States alone. In fact, pain medications are
among the most commonly prescribed drugs. Experts
estimate that the cost of medical treatments for pain,
along with the associated loss of productivity and
income, may be above $125 billion annually (Clay, 2002;
Turk and Melzack, 2001). Unfortunately, many physicians are not adequately trained to assess and manage
pain. Furthermore, insurance companies often do not
cover treatment costs. These problems may be
compounded by patients’ own attitudes about pain
treatment which discourage them from seeking help
(Clay, 2002; Jauhar, 2002; Recer, 2002).
Beginning with the formulation of the "gate control"
theory, pain has been increasingly viewed as having affective and cognitive components in addition to sensoryphysiological ones (Turk and Melzack, 2001). As a result,
psychologists and other professionals who take a mindbody approach are playing greater roles in the assessment and management of pain (Martin, 2002; Schnall,
2002a; Schnall, 2002b; Wilkinson, 2002). While some
methods of pain assessment require the intervention of a
medical doctor, such as diagnostic injection (for a review
see Hogan, 2001), the focus of this review will be on the
methods employed by mental health practitioners.
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Self-report scales usually relate to four major dimensions of pain: intensity, affect, quality, and location
(Jensen and Karoly, 2001). Instruments to assess pain
intensity include the verbal rating scales, visual
analogue scales, and numerical rating scales. Apparently, pain intensity is easy for patients to report, and
most instruments of this category correlate well with
each other. As such, most will work well in nearly all
situations (Jensen and Karoly, 2001). A popular example
is the 15-point scale published in Gracely, McGrath, and
Dubner (1978).
Pain affect, by contrast, is the emotional distress associated with pain. There is some evidence that it is a
construct independent from pain intensity and should
be assessed separately. The affective subscale of the
McGill Pain Questionnaire (MPQ) (Melzack, 1975) is the
most widely used instrument for self-report of pain
affect (Jensen and Karoly, 2001).
Another important dimension of pain is its quality. For
example, patients often describe a pain as "sharp,"
"dull," "deep," or "superficial." While there are currently
very few instruments for this category, the MPQ also
has a sensory scale, which has been shown both reliable
and valid for self-report of pain quality (Jensen and
Karoly, 2001).
A pain assessment is incomplete without examination
of the fourth aspect of pain, its location. The "pain
drawing" is the most common instrument used for this
type of self-report (Jensen and Karoly, 2001). There are
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Pain Assessment and the Mental Health Practitioner: A Mind-Body Approach
numerous examples of these sketches of the human
body, which are marked in the area where the patient
feels pain (see Margolis et al. (1986) for an example).
In addition to a patient’s own report, there are many
ways in which clinicians can detect or evaluate patient
pain on their own. Once used mainly in research, facial
expression of pain has now been applied to clinical
practice (Craig et al., 2001). For example, Chambers et
al. (1996) have developed a manual for application of
their Child Facial Coding System.
Clinicians also make use of numerous psychophysiological techniques to assess pain. These measure either
peripheral or central processes. The former include electromyographic recordings, measures of blood flow and
skin temperature, heart rate and blood pressure, as
well as skin conductance. Positron emission tomography
(PET), functional magnetic resonance imaging (fMRI),
and electroencephalographic (EEG) recordings are
examples of the latter (Flor, 2001).
Another way that clinicians assess pain without
resorting to subjective self-report is by measuring observable pain behaviors. These include verbalizations (even
paralinguistic ones), facial expressions, activity levels,
gesticulations, and postural adjustments. Such measurements are especially useful in behaviorally focused therapies which often aim to limit these behaviors.
Behaviors are particularly important to measure
because, unlike pain per se, they are susceptible to
learning and conditioning influences. As such, clinicians
must examine whether a patient’s environment rewards
pain behaviors such as lying in bed with a day off from
work. Such operant conditioning may make the pain
more "resistant" to treatment (Dworkin and Sherman,
2001; Turk and Melzack, 2001). For example, Keefe et
al. (2001) have developed scoring sheets for the
"osteoarthritis pain behavior observation system" and
the "naturalistic low back pain behavior system."
A thorough pain assessment also includes measure of
patient impairment, which helps in evaluating the
severity of the condition. The degree of impairment
also has important legal ramifications when claims for
financial compensation are filed. Since physical impairment bears only a small association with self-reported
pain (Turk and Melzack, 2001), it is especially important
to conduct a separate evaluation to determine a
patient’s level of function.
To illustrate, Polatin and Mayer (2001) detail how the
capacity of the lumbar spine is tested when quantifying
function in patients with chronic lower back pain.
Measurements typically focus on range of motion,
trunk strength, lifting, and aerobic capacity as well as
task specific tests. Although largely outside the domain
of the mental health professional, it is important that
such reports be provided him by the practitioner who
made the physical evaluation (Battie and May (2001)
review the literature on physical and occupational
therapy assessment approaches).
It is also important to assess a patient’s pain beliefs. For
example, a patient who believes that successful use of
biofeedback or hypnosis implies that his suffering is
nonphysical, and thus less respectable, is less likely to
comply with subsequently proposed treatments. To be
more specific, patient compliance requires that a
patient have appropriate outcome expectancy and selfefficacy beliefs. In other words, he must believe that
the treatment is the correct one and that he is capable
of carrying out the activities it necessitates. The pain
beliefs instrument most widely used and studied is the
Survey of Pain Attitudes (SOPA), originally developed
by Jensen et al. (1987) (DeGood and Tait, 2001). Several
revised and abridged versions are now available, such
as Tait and Chibnall’s (1997) Survey of Pain Attitudes.
Pain coping methods also seem critical to the success or
failure of pain treatment. Although results probably
depend on the circumstances, reinterpreting or
ignoring pain, diverting attention from it, using coping
self-statements or praying and hoping, have demonstrated varying degrees of effectiveness. As such, clinicians should investigate what types of coping methods
a patient tends to employ. The Coping Strategies Questionnaire (Rosenstiel and Keefe, 1983) and the Vanderbilt Pain Management Inventory (Brown and Nicassio,
1987) have been used for this purpose.
Clinicians and researchers alike have realized that pain
patients should not be evaluated in a vacuum, but must
be considered within their social context. As mentioned
earlier, complaining of pain may trigger rewards like
attention from relatives or sympathy from friends.
Conversely, the responses of others may trigger new
reactions in the patient. Furthermore, the patient’s
suffering may have positive or negative effects on his
overall family and social system. Evaluation of these
factors is valuable in determining what methods of
intervention will work best, and how they should be
applied (Carpenter, 2002a; Jacob and Kerns, 2001;
Romano and Schmaling, 2001).
There are many ways by which an individual’s social
context can be assessed, the most traditional being the
clinical interview. Clinicians who prefer a structured
interview approach might consider the Psychosocial
Pain Inventory (Heaton et al., 1985). Self-report measures also exist, such as the Family Environment Scale
(Moos and Moos, 1986), although some have questioned its psychometric properties. Similarly, the West
Haven-Yale Multidimensional Pain Inventory (WHYMPI)
(reprinted in Jacob and Kerns, 2001) has a section
designed to evaluate the patient’s perception of his
social interactions. To be used as a complement, Kerns
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Pain Assessment and the Mental Health Practitioner: A Mind-Body Approach
and Rosenberg (1995) have developed a version of that
scale which allows a patient’s significant other to
provide his perspective of the social environment.
A patient’s psychological state may also affect, or be
affected by, his pain (Sullivan, 2001). It is thus important
to evaluate whether the patient suffers any psychiatric
morbidity that may contribute to his condition or that
has since developed and now requires attention. The
Structured Clinical Interview (SCID) for DSM-IV Axis I
Disorders (First et al., 1997a) and SCID for DSM-IV Axis II
Personality Disorders (First et al., 1997b) are useful for
this purpose, as are the self-report Minnesota Multiphasic Personality Inventory 2 (Hathaway et al., 1989)
and the WHYMPI. Clinicians should also consider the
possibility that psychological factors may, in some
instances, play "the major role in the onset, severity,
exacerbation, or maintenance of the pain," as in the
DSM-IV diagnosis of Pain Disorder Associated with
Psychological Factors (American Psychiatric Association,
1994).
PAIN ASSESSMENT IN SPECIAL POPULATIONS
Pain in children and babies has long been undertreated,
underreported, and even misunderstood. In fact, until
recently many physicians believed that infants could not
even feel pain. This is likely related to the fact that children are often unable, or considered unable, to provide
meaningful information about their pain. Hospital staff
also seem less sensitive to children’s pain, and even lack a
common language with which to discuss the topic (Clay,
2002; Kain et al., 2002). To emphasize some of the confusion in this area, it is noteworthy that some researchers
claim that "providers are unsure which of the myriad
pain measures are best to use" (McGrath and Gillespie,
2001), while others blame "the lack of available and validated pain assessment tools" (Breau et al., 2002).
Given the above, it is critical that clinicians properly
attend to pain assessment in children. Indeed, infants’
pain can only be detected with physiological or behavioral indices, such as the aforementioned Child Facial
Coding System. Nevertheless, McGrath and Gillespie
(2001) have compiled an extensive list of measures to be
employed for older children. Some examples include the
Children’s Headache Interview for migraine and tension
type headaches, the Pain Ladder for acute pain, and The
Oucher for postoperative pain. The latter is also available
in African American and Hispanic versions.
Assessment is made even more complicated when the
child in question suffers cognitive impairment and thus
increased communication difficulties. However, several
new assessment methods are showing promise
(Carpenter, 2002b). For example, Breau et al. (2002)
have recently tested their Non-communicating Children’s Pain Checklist-Postoperative Version on children
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with severe intellectual disabilities and found good
psychometric properties. Their results also suggest that
the observer who completes the form checklist need
not be familiar with the individual child (See Hadjistavropoulos et al. (2001) for an extensive review of selfreport, observational, and physiological measures used
in pain assessment of adults with impaired communication abilities).
In the United States, the elderly constitute a rapidly
expanding segment of the population and are often in
special need of pain management. Yet, this group is a
challenging one to treat for many reasons. To be sure,
some elderly individuals have difficulty communicating
as a result of strokes or other conditions. Many may
also believe that pain is an unavoidable part of aging
and do not seek treatment for their pain (Clay, 2002).
But in actuality, the problem is much broader.
One recent reviewer (Gagliese, 2001) complained that
researchers have not even resolved how to measure
pain variables in the elderly. Studies employing instruments designed for younger and healthier subjects may
not yield valid data for this group. For example, some
researchers have found that older people have trouble
completing pain questionnaires. While research in this
area is still in its infancy, Gagliese (2001) suggests using
the MPQ for this population. Hopefully, as further investigation is performed, we will be more fully equipped to
serve this growing segment of the population.
SUMMARY AND CONCLUSION
Due to surgery, injury, and many chronic conditions, a
large segment of society suffers from significant pain.
Increasingly, scientists and clinicians realize that pain is
not merely a physiological phenomenon, but also has
substantial psychological components and relevant
social variables. As such, the biopsychosocial approach
to pain assessment has become popular. Practitioners
who work within this model make use of a myriad of
new observational, self-report, and interviewing
methods in consonance with traditional medical techniques. While research is far from complete, new and
better methods are being developed to better serve the
pain assessment needs of all segments of the population,
including those that have been neglected in the past.
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