Chronic pain: It’s not an imaginary condition
Misconceptions surrounding the psychological aspects of chronic pain abound in case management. The first is that the pain is imagined, says John Hung, PhD, clinical assistant professor of family practice and community health at the University of Minnesota Medical School in Minneapolis and senior partner of Health Psychology Consultants in Shorewood, MN.
"But the pain is not imagined. There is a psychological component that is adding to the situation, whether it is stress or some sort of unresolved conflict, and that is far different from saying the pain is imagined," Hung says.
In addition, there is often a bias surrounding the term psychogenic, as if the patient is at fault somehow, he says. "I see this attitude as a stereotype that is not helpful from a case management standpoint. These attitudes erect barriers that stop us from trying to understand the person we are working with, and if we don’t understand where the patient is coming from, the whole case is lost."
There are some common psychological reactions to pain. "For many cases we are managing, we may not be talking about a psychiatric disorder. What we may be talking about is a host of psychological reactions that are common but may not meet the criteria for a psychiatric disorder," Hung says. "Although they are not true disorders, if we don’t address them, they may really get in the way of the patients’ recovery." Common psychological reactions to pain include:
• depression;
• anxiety;
• anger;
• confusion;
• relationship disturbance.
Understanding chronic pain syndrome helps case managers develop strategies to assess and manage these patients, Hung says. He asks case managers to consider the following example:
You are driving. A driver runs a red light and rams into you. You bring the car to the garage. After the repairs are made, you begin to notice problems with the car. You return to the garage and point them out. The mechanic assures you that he will check the car thoroughly. When you return to pick up your car for the second time, the mechanic informs you that there was indeed one small problem, but otherwise the car is fine. You drive away and immediately notice the same problems that concerned you before.
"What are you going to do now? You aren’t going back to that garage. Instead, you go to your insurance company and ask to take your car to another garage. You take it to one garage after another, and pretty soon they all look at you funny. They’re treating you like you’re crazy. Do you let it go?"
That’s the profile of a chronic pain patient, Hung says. He cites the following common characteristics found in patients with chronic pain syndrome:
• constant pain for more than six months;
• unresponsiveness to traditional therapy;
• increasing disability, leading to withdrawal from normal activities;
• subjective complaints not in proportion to objective findings;
• significant depression;
• dissatisfaction with therapy;
• "doctor-shopping" behavior;
• chemical dependency;
• fixation on finding a "cure";
• elicits "enabling" behavior.
"We borrow the concept of enabling behavior from chemical dependency treatment," says Hung. "Pain patients often have someone around them who says things such as, Oh, don’t do that. Let me do that for you. You shouldn’t do that.’"
"I once had a patient with chronic back pain. His wife walked behind him with three pillows. He stood in the office and waited for her to check out the chairs. She selected one and arranged the pillows on it for him. She was trying to be helpful, but what she was doing was causing him to focus more on his pain," Hung says.
In addition, case managers should look for enablers in the workplace, he says. If you do an on-site visit to the workplace, look for signs that the client is using his or her pain to get attention from a supervisor or co-workers.
Organizing your approach
Hung suggests case managers use a four-part model to assess their clients’ pain experience. The model includes:
• Physical pain or noxious sensory input. Case managers must attempt to understand the pattern of the pain, Hung says. You ask questions, such as: "Where does it hurt? How often does it hurt?" And from a treatment standpoint, you try to do something to block the pain signal, he notes.
• Motivational/emotional input. "This component looks at how factors such as mood and attentional factors interact with the noxious sensory input," says Hung. "We know that when we’re not focusing our attention on anything but internal signals, we are more aware of those signals. And it is no accident that when you encourage someone to be more active, they also hurt less."
• Conceptual/judgmental input. "This component focuses on what the pain means to us," Hung explains. How the patient assesses the meaning of the pain impacts the pain experience, he says, and that assessment is often affected by past pain experiences. For example, women who have experienced the pain of childbirth have been clinically proven to tolerate pain better than men and than women who have not given birth, Hung says.
• Social/cultural input. Case managers have to recognize the role played by previous pain episodes and the reactions of family and friends to the client at the time of injury. "Social/cultural aspects are especially important when you work with people from other cultural backgrounds. You have take a look at the culture and acceptable ways of expressing and treating pain in the culture," he says.
The four-part model provides the case manager with a framework to conduct a thorough assessment of the pain patient. There are several risk factors in a patient’s psychological history that Hung says should cause case managers to consider the potential for chronic pain syndrome and delayed recovery. Those include:
• history of childhood abuse;
• dysfunctional family background;
• history of substance abuse;
• personality disorder features;
• preexisting or coexisting depression.
"When we are depressed, our energy level is low and we are less likely to try things. We feel more helpless and pessimistic. All these factors put the patient at significant risk for disability and not recovering," Hung says.
Case managers also should look for risk of delayed recovery in a patient’s medical history, Hung adds. Medical risk factors for chronic pain include:
• history of pain and other complaints of unknown etiology;
• history of disability and how the disability was resolved;
• history of compensable injuries;
• history of conflicts with health professionals.
Psychosocial situations and work history also impact recovery, Hung notes. Case managers should look carefully at the following issues:
• marital conflicts, separation, or divorce;
• financial or legal difficulties;
• illness among family members;
• an enabling family member;
• excessive or frequent absences from work;
• interpersonal conflicts at work;
• inconsistent work performance;
• dissatisfaction with employer.
The $64,000 question
Following the initial evaluation of chronic pain patients, case managers should ask a series of questions to learn the source of the pain behavior. Questions Hung asks at this stage include:
• Does the organic pathology fit the illness behavior?
• If the pain behavior appears to be exaggerated, what purpose does the pain behavior serve?
• What events preceded or surrounded the onset of the pain?
• How do patients interpret their pain?
To get a feeling for what patients understand about their pain, Hung suggests case managers ask them: "What is your understanding of what will happen to you physically?"
"If the patient believes that a permanent disability is inevitable, even if it is not true, then you know that from a treatment standpoint, patient education about their problem becomes a very important component," Hung says.
• How has the pain disrupted the patients’ normal behavior patterns? And do they want their normal patterns disrupted?
• How long have their behavior patterns been disrupted?
In addition to recommending that employers encourage an early return-to-work, Hung also recommends that pain patients become involved in extracurricular activities at work. "Bowling league, softball league, company picnic it really doesn’t matter. Just encourage the patient to come," Hung says.
• What do the injured employees want?
"This is the $64,000 question. From a case management standpoint, if you don’t get an answer to this question, you aren’t going to get too far with the tough cases," Hung says. "Don’t settle for a superficial answer. If the patient answers, I want to get better,’ ask, What does it meant to you to get better?’"
• What if an injured employee’s requests are not possible?
If the patient’s desires are unrealistic, Hung suggests case managers call a treatment team conference with the patient. If the patient has an attorney, Hung suggests case managers invite the attorney to attend the team conference as well.
"If the patient has an attorney, you want the attorney there. If the patient realizes that his or her attorney isn’t contradicting you, it has a big impact."
The final step to successful management of the chronic pain patient is removing obstacles to recovery through education, he says. Common obstacles include:
• Medical advice of family and friends.
Patients often get medical advice from people other than their physicians, Hung says.
• Misinformation about the disability claims process.
• Misinformation from other sources, such as the Internet or the media.
• Mistrust of the role of the case manager.
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