DEPARTMENT <EXPERIMENTAL-CLINICAL AND HEALTH PSYCHOLOGY... > RESEARCH GROUP <.GHPLAB.. > PSYCHOLOGICAL EVALUATION. Geert Crombez

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1 DEPARTMENT <EXPERIMENTAL-CLINICAL AND HEALTH PSYCHOLOGY... > RESEARCH GROUP <.GHPLAB.. > PSYCHOLOGICAL EVALUATION Geert Crombez

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3 PSYCHOLOGICAL EVALUATION Why is psychological evaluation important? What should I know about psychological evaluation? What should I evaluate? Conclusions 3

4 A BIOMEDICAL MODEL OF PAIN Tissue Damage Pain Disability

5 The existing biomedical model does not suffice to broaden the approach to disease to include the psychosocial without sacrificing the enormous advantages of the biomedical approach Several levels of analysis needed Molecular, cellular, physiological, psychological, social, & societal level Patient and Health Care Provider interaction is central Psychology/psychiatry is not an art, but a real science

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7 DEFINITION OF PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (IASP, 1986)

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9 BIOPSYCHOSOCIAL MODEL Genetics Disuse Socioeconomic status Personality Doctor Shopping Jobsatisfaction Tissue Damage Pain Disability Coping Depression Stress Catastrophizing Social Support Avoidance

10 TAKE HOME MESSAGE We do not treat backs, arms,, but humans Biomedical perspective is insufficient to understand pain & disability A biopsychosocial perspective is needed 10

11 PSYCHOLOGICAL EVALUATION Why is psychological evaluation important? What should I know about psychological evaluation? What should I evaluate? 11

12 THE CLASSIC STORY Reliability Validity Responsiveness 12

13 RELIABILITY AND VALIDITY 13

14 Reliabiliity Test-retest reliability Internal consistency Validity Content validity To what extent do items reflect the contstruct Construct validity To what extent is research with instruments in line with hypotheses? Criterion validity To what extent is instrument related to relevant outcomes (golden standard & criterion) Responsiveness To what extent is instrument able to assess relevant change

15 The measure that is unconditionnally reliable and valid is no more realistic than claiming to have found a universally effective and harm-free analgesic Amanda Williams, in Psychosocial Aspects of Pain: A handbook for Health Care Providers, p. 100

16 THE REAL STORY We can t have it all It is all about communication 16

17 WHAT DO YOU WANT TO KNOW? Screening Diagnosis Evaluate of the effect of an intervention Evaluate of processes of change in intervention Facilitate communication about psychosocial issues Facilitate initiative and active attitude in patients Case or sample description 17

18 VALIDITY IS NOT ABSOLUTE Which type of validity is important, depends upon what you want Screening: Criterion validity Outcome research: Construct validity and Responsiveness Valid for particular purpose in a particular group in a particular setting Personality measure not appropriate to measure treatment change Beck Depression Inventory not appropriate to measure depressive mood in chronic pain patients Von Korff Grading Scale is not appropriate for Multidisciplinary Pain Centre Never ending story Validation rather than validity It takes a long, long, long, time We can t have it all

19 WE CAN T HAVE IT ALL The more generic the instrument, the less sensitive to change Quality of life instrument: SF-36 or MOS-36 The more generic, the less the construct validity Depression & Beck Depression Inventory Hypochondriasis and MMPI (Minessota Multiphasic Personality Inventory) The more specific the instrument, the less of use in other samples Fibromyalgia Impact Scale, Oswestry Disability Index The more specific, the less known by stakeholders Policy makers (national, regional, ), researchers, 19

20 How interesting is my lecture (until now)? Please provide a number between 0 and 100 0: not interesting at all 100: extremely interesting 20

21 IT S ALL ABOUT COMMUNICATION Individuals disclose what they want In a context of trust and respect Be aware of destructive constructions Psychogenic pain, Somatoform disorder Secondary gain Masked depression Somatisation It is not easy to transform beliefs, feelings and experiences into numbers 21

22 TAKE HOME MESSAGE Try to be precise in what you want? You can t have it all Most of us want too much It s all about disclosure of information Trust and respect are key ingredients Transforming experiences into numbers is not easy 22

23 PSYCHOLOGICAL EVALUATION Why is psychological evaluation important? What should I know about psychological evaluation? What should I evaluate? 23

24 KEY WORKS

25 WHAT SHOULD I EVALUATE Adopt a recovery perspective What are obstacles for recovery or to become active? Talk about the past when discussing the future We can not change the past Personality Physical and sexual abuse Assessing risk based upon stable factors does not allow change 25

26 (Nicholas et al., Physical Therapy, 2011)

27 PSYCHOSOCIAL RISK FACTORS 1. Cognitive factors: how we THINK Beliefs about cause of pain, illness perceptions, appraisals, judgments 2. Emotional factors: how we FEEL worry, fears, anxiety, depression, distress, anger 3. Behavioral factors: how we BEHAVE avoidance, lifestyle, adherence 4. Social context (un)supportive work environment or family

28 ÖREBRO MUSCULOSKELETAL PAIN QUESTIONNAIRE Prediction of chronic disability (absenteeism) 25 items and 11 point scale l 5-10 minutes to respond 2-3 minutes to score Various domains 1. Pain 2. Function/disabilty 3. Distress 4. Fear-avoidance 5. Expectancy about pain course and work resumption 6. Work characteristics

29 THE START BACK SCREENING TOOL

30 NOTHING IS PERFECT and available screening tools are far from perfect 30

31 WHAT WOULD I DO? Adopt a recovery perspective Adopt a person-centered approach Information about experiences, attitudes, beliefs, expectancies, Adhere to community science principles Open source and free of charge instruments Open source and free of charge online system LimeSurvey and clinical dashboard Be very precise and selective in what you want Create a stable and smooth-running system Metaphor: locomotive and wagons 31

32 WHAT WOULD I DO? 32

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34 PROMIS: KEY DOMAINS AND OUTCOMES Questionnaires for medical settings Available in different languages (developed in US) Comprehensability and content validity Reliability and validity Flexible and various forms (4, 6, 8 items) Norms available (but no clinical cut-offs) All raw scores transformed in T-scores: M=50, SD= 10;; all versions (4, 6 or 8 items) Time window of 7 days Computer Adaptive Testing

35 ANXIETY

36 DEPRESSION

37 SLEEP

38 FATIGUE

39 QUALITY OF LIFE & DISABILITY SF-36, SF-12, What? Multidimensional construct Have allready measured a lot Anxiety (8), Depression (8), Sleep (8), fatigue (8), What is missing? Pain, Pain Interference,. Add PROMIS subscales to what we allready have Pain Interference (4,6,8) Participation in Social roles and activities (4,6,8)

40 PAIN INTERFERENCE

41 PARTICIPATION

42 PROMIS-PROFILE & QUALITY OF LIFE Anxiety and depression Fatigue and Sleep disturbance Pain interference Participation in Social and Activities Different forms 29 items (4 item forms+ average pain 10 NRS) 43 items (6 item forms +average pain 10 NRS) 59 items (8 item forms + average pain 10 NRS) Flexible: may drop subscale and add another Still expanding, also child and parent versions

43 PATIENT S GLOBAL IMPROVEMENT OF CHANGE (PGIC)

44 MULTIPLE SOMATIC COMPLAINTS Patient Health Questionnaire-15 (Kroenke et al., 2002) 15 somatic complaints (back pain, stomach ache, headache, diziness, short of breath, ) Free of charge, clinical cut-off, primary care Definitely not the Symtom Check List-90 (SCL-90) Not free of charge Multiple somatic complaints=somatisation

45 Systematic literature review 113 empirical studies between 1989 and Communicate somatic symptoms 2. Unaccounted for by pathological findings 3. To attribute them to physcal illness 4. Seek medical help 100 % 3.4 % 0.0% 1.0%

46 PAIN CATASTROPHIZING & PAIN-RELATED FEAR Pain catastrophizing Scale (PCS, Sullivan et al., 1995) (PINS, PICS, Attal) 16 items, rumination, magnification & helplessness Free of charge, pain free and pain individuals Norms Pain Anxiety Symptoms Scale (PASS-20, McCracken et al., 2002) Short version of 40 items version, subscales: cognitive, fear, escape/avoidance, physiological Free of charge, pain free and pain individuals Norms?, clinical cut-offs? Tampa Scale for Kinesiophobia (Kori & Toddl.,1991) 14 items, fear of (re)injury and movement Free of charge, individuals with musculoskeletal pain Norms

47 PAIN ATTITUDES AND BELIEFS Survey of Pain Attitudes (SOPA, Jensen et al., 1994) 57 items & 7 dimension Control: there are times when I can influence my pain Disability: if my pain continues, I will be unable to work Harm: the pain I feel is a sign that damage is being done Emotion: Anxiety increases the pain I feel Medication: Medicine is one of the best treatment of chronic pain Solicitude: My family does not understand how much pain I have Medical cure: I expect a medical cure for may pain

48 COPING: NO INSTRUMENT Coping Strategies Questionaire (Rosenstiel & Keefe, 1983) 48 items, Distraction;; Ignoring Pain, Reinterpreting Pain, Catastrophizing Praying and Hoping, Invididuals with pain, free of charge, norms Catastrophizing most important important subscale Utrechtse Coping Lijst: NO

49 ACCEPTANCE: NO INSTRUMENT 49

50 NOT EVERYTHING CAN BE MEASURED Information within the experience of patients (memories, attitudes, beliefs, expectations) Disclosure of information In context of trust and respect In a reliable and valid way Not for complex constructs Acceptance, Coping Not for constructs that require contextual information and expert opinion Hypochondriasis, somatisatisation, central sensitisation, alexithymia,

51 TAKE HOME MESSAGE Available screening instruments are far from perfect PROMIS instruments are promising Some other good instruments are available Instruments are important, but require follow-up in interview Not everything can be measured 51

52 CONCLUSIONS Don't do to others what you don't want others to do to you Use a person-centered approach Do not think in dualistic terms Do not medicalize Do not psychologize Adopt a recovery perspective Adopt a community science model Not everything can be measured Unfortunately, the ideal world does not exist 52

53 THANK YOU 53