Behavioral Assessment of Pain Clinical Profile

Transcription

1 Behavioral Assessment of Pain Clinical Profile (For Professional Use Only) The Behavioral Assessment of Pain Questionnaire (BAP) is for the purpose of evaluating patients who are experiencing subacute and chronic benign pain. Patients who do not meet this criteria should not be administered this questionnaire. The BAP should be viewed as a component of a comprehensive assessment protocol and cannot be judged definitive. The results of the BAP need to be combined with additional data drawn from the clinical interview and other assessment devices. Information from the BAP can serve as a useful source of hypotheses about factors which may be maintaining and exacerbating subacute and chronic pain. The patient appears to have completed the BAP in an open and honest fashion. All validity scales were within acceptable ranges. PATINT IDNTIFYING INFORMATION The patient is a 32 year old White single female who is living with her children. She is currently unemployed and has been for more than 24 months. She was working in a skilled trade. The patient has a partial college education. The patient reported that she is experiencing great financial difficulty. Her annual income is between $5,001 and $15,000. This is significantly less than what she was earning before she developed pain. She is not receiving any disability payments. The patient made known that she is involved in active litigation or has retained a lawyer related to her pain problem. Pain characteristics PAIN COMPLAINT The patient reported that low back pain is her most significant pain problem, but she is also bothered by mid-back, upper shoulders, head, neck and jaw pain. She described her low back pain as especially throbbing, hurting, sore, tight, aching and continuous. She disclosed that when she is in pain, she often lies down, tells others to leave her alone, braces herself when she sits and clenches her teeth. She communicated the pain signficantly interferes with her day to day activities (7) and has markedly decreased her enjoyment for social and recreational activities (7).Using a rating scale of 0 to 7, with 7 being most severe, the patient rated her average level of pain intensity as a 4. Over the past week, the patient's pain ranged from a 2 to a 6. Your Clinic Name Copyright 2000 Blake H. Tearnan, Ph.D. and Michael J. Lewandowski, Ph.D.

2 Narcotic analgesic usage The patient did not indicate any use of narcotic medication. Health care utilization In the past year, the patient has consulted 7-8 different physicians and/or chiropractors for her pain complaint. She has had between 16 and 19 physician and/or chiropractic visits over the past 6 month period. Since her pain began on June 26, 1998, she has been hospitalized 1 to 2 times, but reported that has never had surgery for her pain. She estimated the amount of improvement she has received from the health care profession at 20%. Physical activity and pain avoidance The patient's current level of physical activity is 36 percent below the level she reported she was experiencing before developing pain (see Figure 1). She showed reductions in heavy, social, personal care, personal hygiene and domestic/household activities (see Table 1). Her diminished activity level is highest for social activities, followed by heavy and domestic/household activities. Specific activities declining the most were walking long distances, driving long distances, going to parties, being visited by others, dining out, moving furniture and mowing the lawn. F R Q U N C Y Figure 1. Activity Level Changes PAG - 2 -

3 Table 1. Activity Level Patient Mean Scores (0-7) Normative Sample Means* Type of activity Pre-Pain Current Interference Interference SD Domestic/Household Heavy Activities Social Activities Personal-Care Personal Hygiene * mean scores based on a sample of 1012 subacute and chronic pain patients ** +/- one standard deviation She indicated she especially avoids moving furniture, mowing the lawn and vacuuming because of pain. Spousal influence on pain and wellness behaviors The patient did not report having a spouse or partner. PAG - 3 -

4 Physician influence on pain and wellness behaviors There was evidence the doctors may have reinforced her pain behavior (see Figure 3). The patient communicated her doctors on the whole relied primarily on medications to treat her pain and prescribed narcotic medication even after six months following the onset of her pain. F R Q U N C Y Figure 3. Physician Influence on Pain and Wellness Behaviors The patient reported her doctors seldom encouraged her to be physically active or exercise (see Table 3). She replied they usually discouraged her from increasing her physical activity. The patient's doctors seldom criticized or punished her pain behavior (see Table 3). Table 3. Physician influence on pain and wellness behaviors Normative Sample Means Physician Behavior Patient Mean Scores (0-7) MAN SD Physician's reinforcement of pain Physician's reinforcement of wellness Physician's criticism of pain Physician's discouragement of wellness ** ** +/- one standard deviation PAG - 5 -

5 Physician quality The patient's evaluation of her past and current physicians was neutral, suggesting she did not feel strongly positive or negative. Pain beliefs The patient endorsed numerous beliefs about her pain including thoughts that something more could be done to eliminate her pain, believing her pain problem is more than she can handle and thoughts of entitlement (see Table 4 and Figure 4). She also reported fears of re-injury, beliefs that her pain problem was not treated comprehensively and thinking she should be able to control the pain much better. Table 4. Pain beliefs Normative Sample Means Pain beliefs Patient Mean Scores (0-7) MAN SD Catastrophizing Fear of reinjury xpectation for cure Blaming self ntitlement Future despair Social disbelief Lack of med. comp. ** ** +/- one standard deviation F R Q U N C Y CATS = catastrophising; FOR = fear of reinjury; CUR = expectation for cure; BLAM = blaming self: NT = entitlement; DSP = despair; DISB = social disbelief; LMC = lack of medical comprehensiveness Figure 4. Pain beliefs PAG - 6 -

6 Perceived consequences The patient made known she expects a great deal of negative consequences when her pain increases. She acknowledged she is very concerned others will suffer, her productivity will lessen, her pain might remain severe and not diminish and she will suffer psychologically. F R Q U N C Y Coping SI = social interference; P = productivity; PH = physical harm; WP = worsening of pain; PsyH = psychological harm Figure 5. Perceived Consequences of Pain The patient reported that if her pain increased while engaging in various activities, such as shopping for groceries, walking long distances and driving long distances, she would use distraction and stretch. She communicated she would never or seldom ask others for help and take pain medication. The patient acknowledged that she would expect severe levels of pain to occur if she engaged in any of the activities (5.0), and she would be less likely to participate in any of the activities if her pain was at its average (4.3). PAG - 7 -

7 F R Q U N C Y Positive Physical Coping: S = stretching; R = relaxation Positive Cognitive Coping: PSS = positive self statement; D =distraction; NC = non-catastrophising Non-productive Coping: AO = ask others; M = medications; H/P = hope/pray Figure 6. Pain Coping Strategies Mood SCONDARY PROBLMS The patient disclosed that in the past two weeks, she has experienced severe levels of depression (see Table 5 and Figure 7). She admitted to disappointment in herself, feelings of inferiority, feelings of worthlessness, feelings of sadness or depression and feelings of guilt. The symptoms she rated most highly were disappointment in herself and feelings of inferiority. The patient indicated she is currently taking lavil (Amitriptyline) and Norpramin (Desipramine), but it is not known if she was prescribed this medication for pain, sleep or mood related symptoms. Table 5. Mood Normative Sample Means Mood Patient Mean Scores (0-7) MAN SD Depression Kroening Factor Anxiety (muscular discomfort) ** ** ** +/- one standard deviation PAG - 8 -

8 The patient also revealed that she is anxious often (see Table 5 and Figure 7). She endorsed symptoms of cold hands, dry mouth, feeling tense and keyed up, feeling shaky, racing thoughts, trouble staying asleep and stomach distress. She reported that she is bothered the most by feelings of cold hands and dry mouth. Symptoms of muscular tension or tightness, muscle soreness, muscle twitching, fatigue and restlessness were above average (i.e., Kroening Factor). F R Q U N C Y Figure 7. Mood Related Symptoms Use of stimulants/depressants The patient's use of stimulants is minimal ( 115 mg/day). She reported drinking no caffeinated coffee, only one cup of tea and only 1 caffeinated soft drink. She reported smoking cigarettes per day. The patient denied any use of depressants including the use of alcohol, pain medication and tranquilizers. PAG - 9 -

9 SUMMARY The patient reported that low back pain is her most significant pain problem, but she is also bothered by mid-back, upper shoulders, head, neck and jaw pain. She rated the average pain intensity as moderate. She disclosed that when she is in pain, she displays moderate amounts of pain behavior. She reported she lies down, tells others to leave her alone, braces herself when she sits and clenches her teeth. She communicated the pain signficantly interferes with her day to day activities (7) and has markedly decreased her enjoyment for social and recreational activities (7). The patient's use of the health care system is high. In the past year, she made numerous contacts with health care providers, but she has never gone to the emergency room for her pain problem. Since her pain began, she has been hospitalized 1 to 2 times and reported that she has never had surgery for her pain. She estimated she has received minimal improvement from the health care profession. The current activity level of the patient is significantly below the level she reported she was experiencing before she developed pain. The patient attributed the interference in her activity to pain. The patient did not report having a spouse or partner. The patient identified numerous non-productive beliefs about her pain, and let know she expects a great deal of negative consequences whenever her pain increases, especially regarding concerns that others will suffer. The patient estimated the amount of pain she would experience to be very high while engaging in various activities. She reported she would be likely to avoid the activities if her pain was at its average. She communicated she would use distraction and stretch to cope with any increase in her pain. PAG

10 In addition to her pain complaint, the patient admitted to symptoms consistent with depression, anxiety and sleep disturbance. She reported no use of central nervous system depressants. Her intake of caffeine is minimal. The patient is currently taking the antidepressant lavil (Amitriptyline) and Norpramin (Desipramine) but it is not known if she was prescribed this medication for depression, sleep or pain. The purpose of the Behavioral Assessment of Pain Questionnaire (BAP) is to help identify those factors that may be contributing to the maintenance of the patient's pain problem. Below are treatment recommendations based on the findings from the BAP. They are offered as suggestions and general guidelines for treatment: Health care utilization The patient's use of the health care system is high. The patient's over utilization of the health care system might be reduced by helping her better control her tendency to catastrophize and blame her doctors for her pain problem. An attempt should also be made to inform all the doctors responsible for the care of the patient about the treatment program and its goals. Pain behavior TRATMNT RCOMMNDATIONS A combination of feedback, roleplaying, coaching, ignoring by others and differential reinforcement of appropriate behaviors might help when the patient lies down, tells others to leave her alone, braces herself when she sits and clenches her teeth. Video taping might be an effective means of providing feedback to the patient. A biofeedback relaxation training protocol might be useful to help the patient decrease her tendency to brace herself when she is in pain. PAG

11 Social influence on pain & wellness behaviors The patient did not report having a spouse or partner. The patient's doctors should also be told about the importance of reducing any positive reinforcement of the patient's pain behavior, encouraging the patient to be more physically active and not always warning and cautioning the patient about engaging in physical activity. Beliefs about pain The patient's tendency to blame herself for not controlling her pain better, catastrophize, fear re-injury, feel she should not have to experience pain, expect a cure for her pain and doubt that her doctors left no stone unturned in their attempts to treat her pain should be more closely examined and treated using cognitive therapies combined with attempts to increase her physical activity. Perceived consequences The patient showed concerns that when her pain increases others will suffer, her productivity will lessen, her pain might remain severe and not diminish and she will suffer psychologically. Teaching the patient to better control her perceptions of threat when her pain increases is important since high threat appraisal is associated with negative mood states, low rates of activity, and greater pain avoidance. Therapy should be aimed at helping her examine how realistic her appraisals of threat are. Narcotic analgesic usage The patient denied any use of narcotic pain medication. Use of stimulants and depressants The patient's use of caffeine is minimal. Coping strategies The patient should be reinforced for any attempt to use more active and adaptive coping strategies, such as relaxation, instead of her tendency to hope or pray the pain will go away. PAG

12 Sleep disturbance The patient's sleep problems should be managed by teaching her a standard behavioral treatment protocol consisting of more consistent sleep-wake cycles, avoiding the use of stimulants, reducing catastrophizing thoughts about not sleeping, learning a distraction technique, associating getting to bed with feelings of tiredness and learning to get out of bed if a reasonable amount of time has elapsed without falling to sleep. Mood problems The patient's depressive symptoms should be treated by eliminating her use of all CNS depressants, controlling her non-productive thoughts, increasing her social contacts and increasing her physical activity. The patient's anxiety should be managed by teaching her to relax more effectively, helping her control her catastrophic thinking, reducing her fears of re-injury with gradual increases in physical activity, and diminishing any unrealistic somatic concerns. Physical activity The patient should be started on a quota system since her current level of physical activity is significantly below the level she reported experiencing prior to developing pain. The quota system is useful for motivating patients to gradually increase their level of physical activity. The attainment of short-term goals and therapist praise are used as positive reinforcers. The patient's diminished activity level is greatest for the social category and activities such as walking long distances, driving long distances, going to parties, being visited by others, dining out, moving furniture and mowing the lawn. Since the patient reported significant fears of re-injury, her physical activity program should proceed very slowly at first with staff reinforcement for any improvement in activity. The patient's rate of physical activity might improve if efforts were directed at treating her depression. This is because the patient admitted to a significant loss of interest for a variety of previously pleasant activities. PAG

13 SIGNIFICANT RSPONSS The following is a list of significant response items the patient has answered with a score of a 6 or 7, the highest possible values on the questionnaire. Significant response items are items with the highest factor loadings on certain scales or those that at face value appear most clinically significant. While these items may be useful for gaining a better understanding of the patient, they may have been inadvertently checked so caution is urged in their interpretation. ANXITY 279. feeling tense and keyed up 288. dry mouth 291. cold hands DPRSSION/SUICIDAL IDATION 285. feelings of guilt 286. worrying 289. disappointment in yourself 292. feelings of sadness or depression 294. feelings of worthlessness 295. feelings of inferiority 290. feelings of anger 300. decreased interest in socializing 307. being discouraged about the future KRONING FACTOR 284. fatigue 293. muscle tension or tightness 298. sore muscles ATTITUDS AND BLIFS ABOUT PAIN 240. I will always feel inadequate as long as I have pain My family is suffering because of my pain problem I deserve better than to have chronic pain. PAIN CONSQUNCS 317. I am concerned that my pain will make others suffer I am concerned that my pain will interfere with the plans and activities of others I am concerned that my pain will get even worse I am concerned that my pain will take a long time to calm down. COPING STRATGIS hope or pray the pain will go away PAG - 14a -

14 Activity Interference Scale a. domestic/household act b. heavy activities c. social activities d. personal care activities e. personal hygiene activities Avoidance Scale a. domestic/household act b. heavy activities c. social activities d. personal care activities e. personal hygiene activities Spouse/Partner Influence Scale a. criticism of pain b. reinforcement of wellness c. discouragement of wellness d. reinforcement of pain SUMMARY BAP SCALS Mean Scores ( 0-7 ) and associated T-scores Raw T Activity Before Scale Raw T (47) (46) (59) a. domestic/household act b. heavy activities c. social activities (50) (44) (57) (44) (52) d. personal care act e. personal hygiene act (42) (50) Activity Now Scale 3.5 (49) a. domestic/household act 3.5 (57) 3.2 (44) b. heavy activities 0.5 (47) 3.3 (49) c. social activities 1.1 (48) 3.0 (49) d. personal care act 3.0 (50) 0.2 (45) e. personal hygiene act 5.8 (53) Patient Ratings 0.0 ( 0) a. degree of interference ( 0) b. decrease in enjoyment ( 0) c. average pain rating ( 0) d. least pain 2 e. worst pain 6 Physician Influence Scale a. criticism of pain 0.0 (46) Disability Index b. reinforcement of wellness c. discouragement of wellness (46) (59) Pain Behavior d. reinforcement of pain 4.0 (62) a. affective/behavioral Physician Quality Scale neutral b. audible/visible Pain Belief Scale c. total a. catastrophizing 5.6 (66) Pain Descriptors b. fears of re-injury 5.0 (54) a. S.A.T. c. expectation for cure 7.0 (50) b. P.T.D. d. blaming self 3.5 (56) c. T.S. e. entitlement 5.6 (55) d. total f. future despair 3.3 (54) Validity g. social disbelief 2.6 (58) a. neutral h. lack of medical compre. 4.2 (56) b. pain location Perceived Consequences Scale c. missing questions a. social interference 6.8 (68) d. minimum maximum b. physical harm 1.8 (46) e. consistency c. psychological harm 5.0 (62) d. missing scales d. pain exacerbation 5.7 (55) e. productivity interference 6.6 (61) f. average score 5.2 (59) Coping Strategies a. positive physical coping 4.8 (50) b. positive cognitive coping 4.8 (54) c. non-productive coping 2.0 (44) Mood Scale a. depression 5.0 (63) b. muscular discomfort 5.8 (59) c. anxiety 4.4 (63) d. change in weight 2.0 (52) Stimulants and Depressants a. daily caffeine intake 115 (mg) b. medication usage* 2 c. alcohol d. cigarettes cigarettes per day * medication usage lavil (Amitriptyline), Norpramin (Desipramine), (61) (54) (42) (47) 4.0 (53) 4.0 (43) 4.5 (52) 4.1 (48) 25 (47) 6 (60) 0 (47) 3.8 (59) 7 (63) 0 PAG

15 Answer Table Age q1-15 q16 q17-18 q19 q20 q21-23 q24 q25-38 q39-45 q46-54 q55 q56-60 q61a q61b q61c q61d q61e q61f q62-69 q70-85 q q q q q b q a q b q a q q q q q q q q q q q PAG

16 BHAVIORAL ASSSSMNT OF PAIN QUSTIONNAIR PATINT SYNOPSIS The patient appears to have completed the BAP in an open and honest fashion. All validity scales were within acceptable ranges. The patient is a 32 year old White single female who is living with her children. She is currently unemployed and has been for more than 24 months. She was working in a skilled trade. The patient has a partial college education. The patient reported that low back pain is her most significant pain problem, but she is also bothered by mid-back, upper shoulders, head, neck and jaw pain. She described her low back pain as especially throbbing, hurting, sore, tight, aching and continuous. She disclosed that when she is in pain, she often lies down, tells others to leave her alone, braces herself when she sits and clenches her teeth. She communicated the pain signficantly interferes with her day to day activities (7) and has markedly decreased her enjoyment for social and recreational activities (7).Using a rating scale of 0 to 7, with 7 being most severe, the patient rated her average level of pain intensity as a 4. Over the past week, the patient's pain ranged from a 2 to a 6. The patients disability index due to her pain problem is severe. Her disability index on the BAP was 61. Generally, scores greater than 20 are considered significant with scores over 50 considered severe. Patient Strengths ducation: high school or above Narcotic usage: none noted Adaptive coping strategies: would think I can handle it or I can get through this PAG

17 BHAVIORAL ASSSSMNT OF PAIN QUSTIONNAIR PATINT SYNOPSIS cont. Areas of Concern Disability index on the BAP was 61. mployment status: unemployed for more than 3 months Financial status: experiencing great financial difficulty Litigation: attorney retained Pain location: multiple pain locations Pain behavior: excessive pain behavior Pain intensity: high average pain intensity Health care utilization: high use of the health care system Response to health care treatment: little improvement reported Physician reinforcement of pain: significant Physician quality: neutral or negative Pain beliefs: fears of re-injury, beliefs that her pain problem was not treated comprehensively, thoughts that something more could be done to eliminate her pain, believing her pain problem is more than she can handle and thoughts of entitlement Pain appraisal: high expectation of negative consequences Coping strategies: hope or pray the pain will go away Mood disturbance: depression and anxiety Muscle tension/discomfort: excessive Sleep disturbance: trouble staying asleep, PAG