Psychological Factors that Influence Elective Surgical Outcome for Chronic Pain Patients

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When I initially meet pain patients, I attempt to defuse the either/or notion by drawing a Venn diagram of three interlocking circles. I inform the patients that my job is to assist the referring physician in understanding the affective and/or cognitive factors that may be influencing their pain, not to question the validity of whether their pain is real. Initially, I draw the circles with identical sizes. After the evaluation I sit down with the patient and redraw the Venn diagram based on my clinical impression. I point out the interrelated nature of pain and how these factors contribute to their pain experience and form the basis of a treatment plan.

My referring doctors are very knowledgeable about the sensory factor. What they may not appreciate is how the affective and cognitive factors influence the pain signal. (Further) I attempt to explain that pain is a perception and if you want to be successful in your treatment you need to treat the perception. In other words, you may perform an excellent surgery, but patients who are depressed, constant worriers, or magnifying their symptoms, may inform you six months down the road that their pain is worse.

Kern Olson Venn Diagram Pain ModelFigure 1: Melzack's Pain Model 

The darkest shaded area in the very center is pain. The affective and cognitive factors are contributory, especially if the patient is depressed and is exhibiting catastrophic thinking. This is not a stimulus- response linear model, but a circular, interdependent and reciprocal process that is very dynamic. Mood and thinking can change from day to day, which contributes to pain levels being very labile. Another point to keep in mind is that all pain patients are unique, which presents certain challenges to the surgeon not to over generalize or think that all low back pain patients are the same. Overgeneralization may be one more factor that contributes to a growing rate of failed back surgery in the United States.

Recently, I was asked by the State of Oregon Workers' Compensation Division to evaluate a patient who had undergone 12 back surgeries. His neurosurgeon, who had performed all of his previous surgeries, now recommended number thirteen. The patient wanted his back fixed and he would not consider implantable pain options. The patient was very rigid in his thinking, which in his case was counterproductive, since he expected to be pain free. There were a number of cognitive and affective risk factors this patient exhibited that contributed to a poor outcome prognosis. First, he engaged in superstitious or magical thinking. In addition, he was suspicious of having a mechanical device inside his body. Finally, he was a very angry individual, which is considered an affective risk factor. Anger contributes to a constant state of sympathetic reactivity which has a direct influence on pain perception.

Updated on: 09/08/16
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