Psychological Factors that Influence Elective Surgical Outcome for Chronic Pain Patients

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At this point I would like to point out a caveat regarding the use of the MMPI with any chronic illness patient, including pain. The MMPI and its newer versions are the most frequently utilized psychological tests in the medical setting. Further, they are also often misused, especially if the physician relies on a canned actuarial computer-generated report. Actuarial interpretations are based on cutoff scores which may distort interpretations because of construct validity issues. Over the course of my career I have administered over 5000 MMPIs to chronic pain patients. Because of the way the questions are constructed, especially on Scale 1, the typical pain patient will score high, triggering a canned interpretation of conversion. If you or the physician reading the report are not aware of this issue it will lead to a false interpretation. Additionally, this report becomes part of the patient's permanent medical record and this distortion is then perpetuated into the future with profound negative consequences. As a cognitively- based pain psychologist, I interpret elevated Scale 1 scores as predictable considering the form of the questions, and this becomes part of the patient's treatment plan. The MMPI can be a useful tool if used properly by an experienced pain psychologist.

An additional cognitive issue that is often overlooked in the pre-surgical evaluation is the patient's expectation of the surgery outcome. The patient's expectation is clinically significant and should not be discounted, especially if patients expect their pain to disappear. We are creatures of a fix-it culture: if it is broken, let's fix it. This typology usually describes a concrete, rigid thinker. It's black or white; there are no shades of grey. Further, based on my experience, I suspect that this substantial subset of patients who exhibit a cognitive mindset that includes catastrophic thinking and unrealistic expectations, contributes, in part, to a placebo response. This is especially relevant when considering implantable pain technology. The patient may report a successful trial and then six months down the road it stops working and the patient wants it removed. This explanation results in the worst case scenario, which contributes to doubt, not only by the implanting physician, but also by the insurance company who underwrote the procedure.

From a cognitive-behavioral perspective I explain to the patient that surgery and or implantable pain technology is only one tool that is added to the patient's pain management tool box. The more tools the patient has in their pain management tool box, the better able they are to manage their pain. The cognitive therapeutic premise is that the patient accepts the fact that it is their pain; they own it and therefore it is their responsibility to manage it as best they can. Further, these tools, including pharmaceutical, implantable, and behavioral, are not mutually exclusive but should be considered complimentary and additive.

Finally, I would like to propose a theoretical model that continues to be a work in progress. My goal is to offer a pragmatic algorithm that assists the surgeon with patients who present with complex psychosocial symptoms. Patient selection for each surgeon is a very personal process that is greatly influenced by experience, training, and individual temperament. Any decision-making algorithm has to keep this individuality in place, and I believe the following model achieves that goal.

Kern Olson Level of Psychosocial Distress GraphFigure 2

I would encourage each surgeon to list all the psychosocial factors that are relevant to them and give them a weighted score. For example, a serious mood disorder would be weighted higher than a milder mood disorder. Further, keep in mind that the vertical axis is additive.

The psychosocial factors discussed in this article are not exhaustive and each surgeon can add other factors that they feel are important in their decision making process. For example, I did not include such factors as mood, addiction or drug abuse, confusion or memory problems, age, and sleep disorders. Hopefully, we can address these issues in subsequent articles. I am hopeful that the above model gives the individual surgeon a framework to formulate decisions that will promote and contribute to improved patient outcome and welfare.

Updated on: 09/08/16
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