Chapter 11. Behavioral and Psychological Aspects of Pain Flashcards Preview

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Flashcards in Chapter 11. Behavioral and Psychological Aspects of Pain Deck (40):

833. Primary affective symptoms that are present
with chronic pain
(A) generally resolve when the pain is treated
(B) require treatment independent of the
(C) are rare among the elderly
(D) are always reactive or secondary to the
(E) require thorough assessment by a psychopharmacologist

833. (B) Reviews clearly suggest that affective symptoms
require treatment independent of the
patient’s pain, either through pharmacotherapy,
behavioral therapies, or both. Depression is
common in chronic pain populations, with rates
that exceed 50% within some populations.
Unfortunately, physician adherence with respect
to depression screening is poor. Risk of suicide
can be significant with an untreated depression,
and the elderly often fail to undergo adequate
assessment. While consultation by a psychopharmacologist
is desirable, many primary
care physicians and other subspecialists elect to
pharmacologically manage depression.


834. Which of the following include risk factors for
completed suicide?
(A) Age
(B) Substance abuse
(C) History of prior suicide attempts
(D) Chronic medical conditions
(E) All of the above

834. (E) While the ability to predict suicide is poor
even among mental-health clinicians, the above
illustrate commonly accepted risk facts. The
presence of past suicide attempts is another predictor.
The elderly, males, and those with chronic
medical conditions are at great risk for suicide


835. Tricyclic antidepressants
(A) have been shown to assist with reducing
neuropathic pain
(B) have been shown to assist with chronic
(C) should be closely monitored in depressed
patients because of suicide risk and possible
lethality of an overdose
(D) have been infrequently used in the treatment
of major depression
(E) A, B, and C

835. (E) While commonly used in pain practice,
dosing of tricyclic antidepressants is rarely sufficient
to cover comorbid major affective symptoms.
Other commonly used antidepressant
agents or proper dosing should be considered
when significant affective symptoms are present,
with close monitoring given the risk factors
associated with an overdose.


836. Substance abuse risk assessment
(A) is required as a minimum standard of
care with chronic pain
(B) is poorly conducted by most physicians
(C) can reduce medico-legal risk when
chronic opioid therapy is being considered
(D) can be improved by use of brief, standardized
screening questionnaires
(E) all of the above

836. (E) Substance abuse risk screening is generally
considered required in all standard initial medical
assessments, while physician adherence is
poor. Serious substance abuse history and current
substance abuse predicts to poor outcome
with a range of medical treatments. Chronic pain patients may be at high risk for substance
use disorders, and medico-legal risks may be
present for physicians who fail to conduct
adequate screening and refer the patient for


837. Patient self-report data is
(A) highly reliable when a spouse is present
in the interview
(B) always subject to bias
(C) often unreliable with assessment of
substance abuse, unless toxic screening
is used
(D) more reliable when an anxiety disorder
is present
(E) all of the above

837. (B) The field has an inherent handicap because
of the subjective nature of pain. Bias is always
present with self-report, and reliability of pain
ratings is poor. Presence of a significant other
can greatly assist with validation of patient selfreport,
while the bias remains. Substance abuse
assessment is necessary, self-report remains the
only practical strategy, and toxic screening does
not necessarily improve the veracity of the
patient’s report. Comorbid psychologic symptoms
further compromise self-report. While
assessment of pain level is necessary, additional
assessment of other outcome variables remains
important, that is, functional activities, return
to work, medication adherence.


838. Spouse “oversolicitous” behavior
(A) can be assessed with the Minnesota
Multiphasic Personality Inventory-2
(B) can contribute to poor treatment outcome
(C) controls most of the variance in predicting
disability and substance abuse
(D) is generally a reflection of positive social
support, and should be reinforced
(E) all of the above

838. (B) The construct “oversolicitiousness” has
been studied since the mid 1980s with the work
of Andrew Block. The oversolicitious spouse
is considered overly attentive to pain and disability
behavior, potentially influencing the
patient’s report of pain and reinforcing pain
behaviors. Several standardized assessment
instruments address degree of spouse oversolicitiousness,
such as the Multidimensional
Pain Inventory. Therapy programs can incorporate
treatments designed to modify spouse
behavior and thereby improve the patient’s
treatment outcome, while other factors may
control more of the variance with respect to
overall pain level, disability, or other comorbid
psychiatric symptoms.


839. Somatization disorder
(A) commonly develops in the elderly, as a
result of poor communication with
health care providers
(B) precludes the presence of an organic
disease or disorder
(C) develops in adolescence, with symptoms
disappearing by the age of 35 years
(D) implies the patient is intentionally
“making up” symptoms
(E) complicates the pain physician’s ability
to evaluate effectiveness of the treatment

839. (E)Adiagnosis of somatization disorder is often
missed in subspecialty practices. While the
patient may present with a discrete pain complaint,
comprehensive assessment and adequate
record review may reveal a history of multiple
somatic symptoms. The Diagnostic and Statistical
Manual of Mental Disorders (Fourth Edition, Text
Revision) (DSM-IV-TR) outlines criteria that
include onset prior to age 30 years, and multiple
unexplained symptoms persist with varying
severity over many years. Patients are not “malingering”
or feigning symptoms with this diagnosis.
Comorbid disorders such as posttraumatic
stress disorder and history of emotional trauma
may be present. Patients may undergo questionable
interventional or surgical procedures, and
develop secondary iatrogenic problems. Other
comorbid medical diagnoses may be missed, and
ongoing assessment is compromised as a result of
the patients impaired self-report. Patient resistance
to psychologic intervention is great and outcomes
for those who agree to treatment are
generally poor. Coordinated management of the
somatization disorder patient through primary
care often is the mainstay, while pain specialists
may assist with close communication among


840. Anxiety symptoms are common among most
patients with chronic conditions, and
(A) structured anxiety questionnaires can
replace time-consuming interview questions,
providing they have sufficient
reliability and validity
(B) anxiety symptoms with acute pain often
abate after adequate treatment of the pain
(C) posttraumatic stress disorder is common
when a history of domestic abuse is
(D) anxiety symptoms rarely abate after
adequate treatment of pain
(E) both B and C

840. (E) Anxiety symptoms are common with all
chronic pain and many acute pain conditions,
while few pain patients meet psychiatric diagnostic
criteria for an anxiety disorder, for example,
posttraumatic stress disorder. In many
cases, anxiety symptoms may abate when
proper pain treatment occurs, either in acute or
chronic pain. Some conditions do predict to a
high likelihood of anxiety disorder, such as history
of domestic abuse. Anxiety may persist in
other chronic pain conditions and combined
behavioral and pharmacologic treatments are
often required. While many pain questionnaires
address anxiety symptoms, screening questionnaires
do not absolve the clinician from conducting
an adequate interview assessment.


841. With a work related spine injury, pain and disability
are most dependent upon
(A) the level of the disc herniation
(B) the employee’s appraisal of his work
(C) the patient’s level of depression
(D) the adequacy of the patient’s pharmacotherapy
(E) all of the above

841. (B) While there are multiple factors associated
with pain and disability and individual differences
must be addressed, most investigations
point toward the patient’s appraisal of the
work setting as a major factor influencing pain and disability, regardless of injury severity.
Psychosocial factors associated with coping
within a difficult work environment may be
moderating factor. Investigators have not suggested
malingering or feigning of pain as an
explanation of these results.


842. In general, a successful return to work with
back pain is more likely if
(A) the patient is placed on light duty
(B) the return to work is rapid, ideally
within 12 months of the injury
(C) ergonomic job modifications are made
at the work-site
(D) time-release versus short-acting analgesics
are employed
(E) psychological job counseling is instituted
shortly after the injury

842. (B) Timing appears to be a major factor with
respect to successful return to work, with a rapid
drop off in success after the 12-month mark.
Despite widespread use, “light duty” strategies
have shown mixed results, and greater success
has been shown where no restrictions were proposed.
The role of pharmacotherapy and return
to work hasn’t been adequately studied. While
there may be a role for early psychologic counseling
in some cases, data with respect to effect
of counseling within this narrow time period
are limited. Similarly, ergonomic modifications
have shown limited effect, particularly in cases
where chronic pain is present. When a patient’s
condition becomes more chronic, highly structured
functional restoration rehabilitation
approaches have shown the most promise with
respect to return to work.


843. Biofeedback assisted relaxation has been
shown to be effective in reducing frequency,
duration, and severity of pain with
(A) myofascial pain conditions and
(B) cluster headache
(C) trigeminal neuralgia
(D) postherpetic neuralgia
(E) all of the above

843. (A) EMG and thermal biofeedback involve the
surface monitoring of physiological responses,
with ongoing graphic visual or audio feedback to
the patient. Relaxation training or cognitive techniques
are employed to master control over the
physiologic response, and additional practice
techniques assist the patient to generalize the
relaxation response to other settings. Studies suggest
that adjunctive use of the biofeedback equipment
offers benefit to some patients, and may be
more effective with particular pain conditions.
Positive outcomes have been demonstrated with
migraine and various pain conditions considered
as myofascial. Results with cluster headache
are less promising, as are results with other specific
neuropathic pain conditions. Nonetheless, a
positive general relaxation effect has been shown
with multiple pain conditions.


844. In general, compliance rates or “adherence”
with pharmacotherapy recommendations is
(A) 70% if a chronic medical condition is
(B) dependent upon the severity of the
chronic condition
(C) greater with elderly patients
(D) dependent on the patient’s intelligence
(E) improved when the pain clinician is
“emphatic,” and readily accepts the
patient’s report of pain severity

844. (B) Poor adherence is common with any chronic
medical condition and worse when comorbid
psychiatric disorders are presence. Adherence is
defined as the extent to which the patient’s behavior
coincides with medical recommendations. The term “compliance” has fallen in disfavor, as
the term “adherence” assumes a more nonjudgmental
assessment of the patient’s behavior.
Adherence is unrelated to age, sex, race, or intelligence.
Notwithstanding extensive research on
improving adherence, effects of various interventions
have been modest with respect to changing
difficult patient behavior. Within the field of
pain medicine, particular attention has been pain
to adherence when chronic opioid therapy is considered.
Screening for risk factors and urine toxicology
combined with structured treatment may
result in improved adherence, while studies are
still lacking. Adherence may be improved by simplified
dosing schedules, increased frequency of
office visits, reinforcing the importance of adherence
when counseling the patient, and enlisting
family members in the treatment plan. Where a
language or cultural barrier is present, adherence
may improve by enlisting skilled interpreters and
clinicians who have an in-depth understanding of
the particular cultural issues.


845. Factors suggestive of a possible problematic
course with chronic opioid therapy include
(A) tobacco use
(B) history of inpatient detoxification
(C) a high score on a standardized chronic
opioid therapy–screening instrument
(D) comorbid psychiatric diagnosis such as
posttraumatic stress disorder
(E) all of the above

845. (E) Screening for chronic opioid therapy has
received increasing attention, as risk factors
have received closer scrutiny and outcomes
have been poor with some patients. Among
others, all of the above choices have been predictors
of poor outcome. Several screening
questionnaires have been developed with adequate
reliability and validity, and these may
assist the clinician in formulating an effective
treatment plan. Examples include the SOAPP
(Screener and Opioid Assessment for Patients
with Pain) and DIRE (Diagnosis, Intractability,
Risk and Efficacy Score) rating scale. Tobacco
use, history of detoxification, and various
comorbid psychiatric diagnoses may predict
to a problematic course. Many State Medical
Board Model Pain Policies suggest that special
attention be paid to these at-risk patients when
chronic opioid therapy is considered.


846. Adiagnosis of posttraumatic stress disorder is
(A) uncommon among pain patients who
have domestic violence histories
(B) a risk factor in the development of a
treatment-resistant chronic pain
(C) not predictive of poor adherence when
treating chronic pain conditions
(D) present in 70% of motor vehicle accidents
who report neck pain after the
first 12 months
(E) generally resolved within the first few
weeks of a major trauma, provided that
the patient has adequate treatment of
acute pain

846. (B) Posttraumatic stress disorder (DSM-IV-TR)
is classified as an anxiety disorder and often
co-occurs with other psychiatric disorders.
Posttraumatic stress disorder has been considered
a risk factor with respect to development
of treatment resistant chronic pain disorders.
Patients may have frequent or recurrent periods of hyperarousal, and chronic symptoms may
suggest a problematic course for pain treatment.
While present in few motor vehicle accident
victims after 1 year, other trauma precipitants
such as early physical/sexual abuse or extensive
domestic violence often result in chronic
symptoms and a more complicated treatment
course. Comanagement with a mental-health
specialist is always recommended.


847. Patient pain ratings
(A) should be documented by the clinician
during each visit
(B) are not particularly reliable
(C) are poor predictors of disability
(D) should be supplemented by other measures
when chronic pain is present
(E) all of the above

847. (E) Despite issues of reliability and the subjective
nature of pain ratings, pain clinicians are
required to record the patient’s self-report, that
is, the “fifth vital sign.” Reliability is improved
with increased frequency of ratings, and special
populations may require a modification and/
or improved description of the rating scale.
Clinical relevance of ratings with chronic pain
may be less than acute pain, as multiple problem
areas are often present. Other adjunct
assessments could include standardized measures
for quality of life. The pain clinician can
also supplement pain ratings through documentation
of other objective indicators, for
example, the patient may state that “I can now
walk 20 minutes...I returned to work...I’m using
medication as prescribed now....”


848. Commonly used quality of life measures
(A) Beck Depression Inventory and CES-D
depression screening questionnaire
(B) Short Form-36 (SF-36) and the Sickness
Impact Profile (SIP)
(C) Brief Pain Inventory
(D) Headache Disability Index
(E) MMPI-2

848. (B) While the other symptom-specific instruments
are commonly used in pain, clinic settings,
the SF-36 and SIP illustrate an example
standardized instruments that are becoming
increasingly important in health care settings as
efforts are made to evaluate overall outcome.


849. Psychological screening for spinal column
stimulation should
(A) weigh the patient’s realistic and unrealistic
expectations for outcome
(B) exclude patients with a major depression,
given a probable poor prognosis
(C) underscore the patient’s likelihood for
improved work capacity after successful
(D) address possible malingering by the use
of standardized psychologic testing
(E) all of the above

849. (A) There do appear to be predictors of a problematic
course with spinal column stimulation,
while these tend to be the same predictors that
suggest poor outcome with most pain treatments.
Nonetheless, predictive validity studies
have been few. Screening by a psychologist may
help to better delineate possible predictors, and
formal screening is often required by third party
carriers. Realistic patient expectations may be
particularly important with neurostimulation
procedures. For example, spinal column stimulation
may offer the patient pain relief, while
structured rehabilitation approaches tend to
show better outcome when goals such as return
to work or improved function are targeted. Patients with particular psychiatric conditions
do not necessarily have a poor outcome if their
symptoms can be readily treated, for example,
major depression. Conversely, a diagnosis of
somatization disorder or substance use disorder
may predict a more difficult course of treatment.
In some cases, problem areas can be
identified and treated prior to embarking on
neurostimulation, and outcome may be better.


850. There is a greater likelihood of improved function
and return to work when
(A) passive rehabilitation approaches are
paired with biobehavioral approaches
(B) interventional approaches are paired
with cognitive therapies
(C) active rehabilitation approaches are
combined with cognitive therapies
(D) complimentary medicine approaches are
combined with cognitive therapies.
(E) opioid therapy is combined with a light
duty return-to-work schedule.

850. (C) “Passive” rehabilitation approaches are
considered to be less effective than “active”
interventions when function or return to work
are considered. Active approaches involving
quota-based exercise may help the patient to
reduce fear of pain and activity. Passive
approaches sometimes rely on the patient being
less involved, and may depend upon the clinician
to provide the relief. Many active
approaches have been coupled with cognitive
therapies, resulting in a greater effect. Fewer
definitive studies have addressed results of
return to work with interventional procedures,
opioid treatments, or complimentary therapies.
While most investigations have been conducted
with chronic back and neck populations,
fibromyalgia and other conditions tend to
show better functional improvement with more
active versus passive rehabilitation approaches.


851. In part, factors associated with the placebo
effect include
(A) patient and clinician expectations
(B) past learning and conditioning
(C) neurotransmitter responses
(D) credibility of the treatment intervention
(E) all of the above

851. (E) Research on the placebo and nocebo effect is
well-established in the pain field. A placebo
effect can be as high as 100%, depending upon
multiple variables. It’s generally acknowledged
that interventional treatments may have greater
placebo effect than oral medications, and surgical
approaches potentially have the greatest
effect. While “noise” associated with reference to
the placebo effect if often addressed in clinical
trials, efforts to understand and “harness” the
role placebo in clinical care has received growing
attention. Investigations have revealed that
clinicians tend to overestimate the impact of
their treatments and underestimate the power of
placebo or other nonspecific factors.


852. A patient with chronic daily headache and
myofascial neck pain improves after a series
of trigger point injections. The effect could be
attributed to
(A) the treatment intervention
(B) the natural course of the illness or
“regression to the mean”
(C) placebo effect associated with the injections
(D) other concurrent treatment changes that
may have occured, for example, patient
terminated a prophylactic treatment in
anticipation of the injection series
(E) all of the above

852. (E) Determining outcome based upon any particular
treatment remains difficult with chronic pain
conditions, and the effect on nonspecific or other
treatment variables always must be considered.


853. Pain support groups and online support organizations
(A) may reinforce the patient’s somatic
overconcern and promote disability
(B) provide a valuable resource of information
with chronic pain conditions, and
help to minimize distress and tendency
to feel isolated
(C) may provide the pain patient with critical
evaluations of his/her health care
(D) are not a replacement for psychologic or
psychiatric treatments
(E) all of the above

853. (E) Studies of support organizations and volunteering
suggest that these approaches may
be a valuable resource for the pain patient,
while the pain physician should use caution
with respect to referral. Some organizations
such as the American Chronic Pain Association
provide admirable support and information,
while fringe advocacy groups may increase the
patient’s distress and divert the patient from
the most appropriate treatments.


854. Historically, the traditional operant-conditioning–
pain-rehabilitation programs
(A) expected the patient to increase activity
levels until pain became severe
(B) measured level of pain as an integral
component of assessment
(C) regarded as-needed analgesic consumption
as a “pain behavior”
(D) established objective functional and
recreational goals after the pain was
adequately controlled
(E) all of the above

854. (C) One of the first and most well known operant
pain rehabilitation programs for chronic
noncancer pain was established in Seattle
Washington in the late 1970s under the guidance
of Drs Wilbert Fordyce and John Loesser.
On an intensive inpatient basis, patients were
taught to increase function despite pain, recreational
and other “well behaviors” were
socially reinforced, and “pain behaviors” were
ignored. Examples of pain behaviors included
grimacing, pill consumption, or complaints of
pain. Objective program goals were established
prior to starting treatment. Functional outcomes
were positive, and programs with varying
levels of operant focus were developed
throughout the country. Economic pressure
forced programs to convert to outpatient services,
and operant oriented “functional restoration
programs” thrived into the late 1980s.
Additional economic pressures ensued and
most programs closed. Currently, there appears
to be a resurgence of programs with this focus,
given continued perceived need.


855. The Minnesota Multiphasic Personality Inventory
(A) is a brief, “clinician-friendly,” self-report
questionnaire that does not require
interpretation by a clinical psychologist
(B) has rarely been challenged with respect
to its utility in chronic pain settings,
with most pain psychologists accepting
the MMPI-2 as the testing instrument of
(C) is a 566 item true/false self-report
instrument used to assist with the
assessment of overall psychopathology
(D) has limited utility in clinical settings,
primarily because of the lack of chronic
pain normative data
(E) can assess whether a patient is malingering
with respect to report of pain level

855. (C) The MMPI-2 has been widely administered
in pain clinic settings as a general measure of
psychopathology, while its use has declined over
the last 15 years. Results provide an overall
measure of psychopathology, while some clinicians
with extensive training in the MMPI-2
argue that specific psychologic deficits can be
ascertained from the results. The focus on psychopathology,
its length (500+ items), and training
requirements for interpretation have resulted
in a reduction in its use. Other psychologic tests
specifically developed for chronic pain have seen
increasing use, while a long history of predictive
validity studies suggests that the MMPI-2 will
likely continue to be used in pain clinic settings.


856. Which of the following are commonly employed
cognitive behavioral techniques with pain conditions?
(A) Cognitive restructuring, problem solving,
and dialectical behavior therapy
(B) Progressive muscle relaxation, autogenic
training, and psychoanalytic
(C) Contingency management, stimulus
generalization, and operant conditioning
(D) Surface electromyographic (EMG)
biofeedback, thermal biofeedback, and
muscle reeducation
(E) All of the above

856. (A) Cognitive therapies include the use of specific
techniques targeted toward the patient’s
perception of pain or disability. Maladaptive
thought patterns are altered or “restructured.”
Dialectical behavior therapy offers a similar,
highly structured approach aimed at systematically
modifying thoughts, often directed at
disordered cognitions present with chronic
depression or posttraumatic stress disorder.
While most behavioral specialists agree that
relaxation training, biofeedback, and operant
strategies (contingency management, stimulus
generalization, operant conditioning) have a
large cognitive therapy component, these treatments
generally are considered separate from
standard cognitive approaches.


857. Apatient returns to work despite a fear of reinjury,
and remains in the work setting until the
fear gradually subsides. From a learning theory
standpoint, this is considered
(A) punishment
(B) in vivo exposure
(C) negative reinforcement
(D) intermittent reinforcement
(E) systematic desensitization

857. (B) In vivo exposure requires the patient to
remain in the feared setting until the anxiety
subsides. If the patient leaves at the height of
the anxiety (or during the most severe pain),
the patient may increase the severity of the
phobia. Studies support a rapid return to work
for work-injured patients in an effort to provide
them with an in vivo exposure and reduce fear
of activity. However, it’s important that the
patient have a “success,” and remain in the
work setting until the anxiety subsides. Ideally,
the patient discovers that engaging in work
tasks does not result in a reinjury. The worker
may have intermittent exacerbations of pain,
but also learns that pain subsides and does not
result in greater physical “harm.” The construct
of punishment reduces behavior, while negative
reinforcement increases behavior, for example,
the patient terminates the aversive work
setting by leaving. Systematic desensitization is
a treatment method that generally requires to a
graded exposure using guided imagery within
a therapy setting. Work-simulation or workhardening
programs employ a similar principle
by gradually reducing the patient’s fear of
work activity or increased pain. After achieving
some level of relaxation and confidence, the
clinician then introduces the patient to the in
vivo work setting


858. Hypnosis is often used to
(A) reduce acute pain and relax the patient
(B) improve adherence
(C) treat posttraumatic stress disorder
(D) treat cluster headache
(E) both A and D

858. (A) Hypnotic analgesia has a long history as an
adjunctive treatment for pain, with formal procedures
for hypnosis dating back several hundred years. Some argue that the effects are similar to
other standardized relaxation procedures, and
self-hypnosis resembles many relaxation techniques.
Positive effects have been shown with
acute and chronic pain conditions. Studies
addressing patient adherence suggest a role for
multiple complex variables, and hypnosis has
not been proposed as an important intervention
for adherence. Other behavioral and pharmacologic
strategies have shown much greater
effect with conditions such as posttraumatic
stress disorder or cluster headache.


859. Apatient is being considered for an implantable
opioid pump. Which of the following can be
considered a reasonable outcome, based upon
current evidence-based reviews?
(A) Reduced side effects from oral opioid
(B) Return to work and increase in recreational
(C) Reduced pain and depression
(D) Improved aerobic capacity and reduced
side effects from opioids
(E) None of the above

859. (A) While implantable pumps have demonstrated
effect with respect to reduced pain and
reduced side effects from oral opioid therapy,
objective gains with respect to improved function
or change in emotional status are lacking.
Psychologic techniques have been successfully
employed to better prepare patients for
implantable devices, most notably specific cognitive


860. “Mind-body” and structured “stressmanagement”
programs often employ
(A) short-term, time-limited treatment
(B) monitoring of stressors and precipitants
of pain
(C) cognitive therapy to reduce perception
of pain and control over all symptoms
(D) relaxation training
(E) all of the above

860. (E) Mind-body and structured stress-management
groups have been integrated into overall
patient care, with promising results. These techniques
may buttress rather than replace individual
therapeutic approaches, especially in
cases where chronic disability and more significant
comorbid psychiatric disorders are present.


861. Cognitive behavioral treatments with pain in
children might typically include all of the following
(A) enlisting parents to assess mediating
stressors and reinforce positive coping
(B) structured play therapy
(C) relaxation training with possible adjunctive
use of biofeedback
(D) rehearsal of positive cognitions
(E) efforts to return the child to school in
order to minimize school phobia and
disability behavior

861. (B) Cognitive behavioral treatments for children
with acute and chronic pain are typically short in
duration and goal oriented. Pain and painrelated
distress may be targeted, and functional
activities may be reinforced. Involvement of the
family or school can optimize outcome. While
traditional play therapy approaches are common
in child-treatment settings, the structure and
short-term nature of cognitive therapy interventions
would unlikely include this approach.


862. Functional sleep disorders are common with
chronic pain conditions, with as many as 80%
of pain patients reporting problems with sleep.
Behavioral approaches have consistently been
shown to be superior to pharmacotherapy
approaches. Which of the following is included
in a behavioral approach to functional sleep
(A) Instruction in proper sleep hygiene and
use of stimulus-control techniques
(B) Relaxation training and cognitive interventions
(C) Self-monitoring of sleep, with particular
focus on sleep habits and anxiety symptoms
(D) Addressing common precipitants of
poor sleep such as depression, inappropriate
use of pharmacologic sleep aids,
and/or substance use
(E) All of the above

862. (E) Sleep disorders are exceedingly common
among patients with chronic pain conditions,
with prescription and over-the-counter sleep aids
often providing limited benefit. Recent investigations
have suggested that myofascial pain
complaints may be precipitated or worsened by
poor sleep, and disrupted sleep is well established
as a precipitant of migraine headache.


863. Temporomandibular disorders have been most
effectively treated by a combination of
(A) interventional and biobehavioral techniques
(B) biobehavioral and oral/dental/occlusal
appliance therapy
(C) physical therapy and biobehavioral
(D) low-dose chronic opioid therapy and
thermal biofeedback
(E) none of the above

863. (B) Defining temporomandibular disorders
remain a problem, as with many chronic pain
conditions. However, the role of myofascial
factors is generally accepted, and recommendations
from evidence-based reviews have consistently
supported a role for cognitive and
relaxation approaches. Dentists with an orofacial
pain subspeciality also often manage these
patients, and studies have shown the best effect
with combined therapies. Opioid therapy,
physical therapy, and various interventional
procedures have been less well-studied with
chronic temporomandibular disorders.


864. A patient presents with symptoms of chronic
hand-arm pain, possibly neuropathic in origin,
as well as a diagnosis of fibromyalgia with
associated disability and depression. Which of
the following is best treatment for this patient?
(A) Referral to cognitive therapy
(B) Multidisciplinary treatment, where
behavioral interventions are integrated
into the patient’s care
(C) Interventional treatments, where appropriate,
while concurrently referring the
patient to a psychologist with a specialty
in pain management
(D) Pharmacotherapy as a first-line treatment,
with appropriate psychologic screening
for risk factors if opioids are considered
(E) Treatment modalities that directly
address the patient’s presenting diagnosis,
for example, a diagnosis of complex
regional pain syndrome may require
interventional procedures and/or neurostimulation,
referral for behavioral
treatment, and eventual referral to
physical therapy

.864. (B) When disability and depression are present
with multiple chronic pain conditions, the minimum
standard of care requires a multidisciplinary
effort. Sequential efforts that start with
pharmacotherapy or interventional treatments
may extend the patient’s period of disability and
distress, and cross-discipline multidisciplinary
coordination remains the standard of care.
However, access to some specialty care may limit
the pain physician’s options, as psychological or
rehabilitation services may be denied by an
insurance carrier. Nonetheless, the data continue
to support a multidisciplinary approach from
the onset of the patient’s care.


865. Addiction can co-occur with chronic pain disorders.
If chronic pain and an addictive disorder
co-occur, the patient
(A) can be effectively managed when the clinician
primarily relies on interventional
(B) requires referral for comanagement by
an addiction specialist
(C) may show a decrease in addictive
behavior, as many patients engage in
addictive behavior because of inadequate
treatment of pain
(D) requires an inpatient detoxification from
the addictive substances prior to pain
(E) should never be treated with chronic
opioid therapy

865. (B) The AAPM (American Academy of Pain
Medicine)/APS (American Pain Society)/ASAM
(American Society of Addiction Medicine) joint
statement states that “addiction is a primary,
chronic, neurobiological disease, with genetic,
psychosocial, and environmental factors influencing
its development and manifestations. It is
characterized by behaviors that include one or
more of the following: impaired control over
drug use, compulsive use, continued use despite
harm, and craving.” The IASP (International
Association for the Study of Pain) Core
Curriculum further asserts that “adequate pain
treatment will be difficult or may fail without
concurrent treatment of addiction.” Given the
complexity of addictive disorders, comanagement
is necessary. In many cases, addictive
behavior can be managed on an outpatient basis.
Opioid therapy is not an absolute contraindication
in cases where the patient displays additive
behavior, while care should be taken by close comanagement of the patient by other relevant


866. In population-based studies, women suffering
from pain
(A) typically do not report more severe and
frequent pain than men
(B) may be at greater risk for specific pain
disorders, for example, fibromyalgia,
temporomandibular disorders, and
(C) have been shown to be at greater risk
because of endogenous and exogenous
sex hormone changes
(D) may be subject to multiple psychosocial
and cultural influences that impact on
report of pain
(E) B, C, and D

866. (E) Sex differences with respect to pain are well
established, and recent animal studies appear to
buttress these results. Women may report more
frequent and severe pain than men, and hormonal
factors, in part, may play a role. Psychosocial differences
also appear to play a role. Conversely,
women also have shown a more robust treatment
effect than men with rehabilitation and multidisciplinary


867. Aperson’s degree of belief that he/she can successfully
manage aspects of their pain, including
their pain level, is termed
(A) catastrophizing
(B) self-esteem
(C) cognitive coping skill
(D) self-efficacy
(E) locus of control

867. (D) While all of the above constructs are addressed
in cognitive treatment, self-efficacy is the defined
construct. Self-efficacy is often associated with
the early work of Albert Bandura, and researchers
in the pain field have developed relevant assessment
instruments. Self-efficacy is addressed clinically
when the patient is trained to internalize the
belief that he/she is capable and has the skills to
managing exacerbations in pain, coordinating
his/her medical care, or improve on some specific
functional task.


868. The construct of operant conditioning would
apply to the following patient vignette:
(A) A worker has an acute back injury while
lifting an object at work, experiences
immediate pain and associated anxiety,
and thereafter develops an unrealistic
fear of any future lifting behavior
(B) A patient uses a short-acting opioid
after an exacerbation of pain. He learns
to take his pill when his pain reaches a
certain level. His pill-taking behavior is
initially reinforced by the effect of the
analgesic or other nonspecific factors
that contributed to his pain reduction
(C) A patient in physical therapy engages in
her exercise “until I can’t stand the
pain,” then discontinues the exercise,
seeks bedrest, and rapidly feels better.
She learns that escaping from physical
therapy and lying down reduces her
pain, and continues this behavior
(D) A patient becomes markedly anxious
during the preparation for an interventional
procedure, and the procedure is
terminated prematurely owing to her
anxiety. Upon returning to the pain clinic,
the patient leaves the procedure room as
her anxiety escalates. She has become
phobic of interventional procedures
(E) Both B and C

868. (E) While all of the answer choices could
include components of operant and classical
(respondent) conditioning, choices (B) and (C)
address the issue of reinforcement. In contrast,
“classical” conditioning involves the pairing
of a neutral (lifting, preparation for a procedure)
with an immediate noxious (pain, anxiety)
stimulus or pleasant stimulus. Often after
one or repeated trials, reintroducing the “neutral”
stimulus (a nerve block, a lifting episode)
produces the unwanted response, that is, anxiety
as outlined in a cases above. With respect
to operant conditioning, a behavior is reinforced
and thereby increases in frequency.


869. There is empirical evidence to support
(A) the construct of a “pain prone personality”
(B) the concept that chronic pain is “masked
(C) malingering as being rare, less than 1%
with work injury-related chronic pain
(D) the assumption that psychologic trauma
may increase the likelihood of developing
a treatment-resistant chronic pain
(E) all of the above

869. (D) The construct of a “pain prone personality”
has largely been discredited, as has the construct
of pain as a “masked depression.”
However, multiple psychosocial factors appear
to be predictors of developing chronic pain disorders,
while they are not necessarily causes.
Rates of malingering, or consciously lying
about disability and pain, appear to vary. Pain
physicians are poor at assessing malingering,
while most investigations agree that rates are higher in any circumstances where active
adversarial/litigation is present. It is most
important to note that malingering can occur
when a legitimate medical or psychiatric condition
is also present.


870. A patient arrives at the pain center with persistent
facial pain, secondary to a fall 6 months
earlier. She has a history of other pain complaints,
and reports that she follows with a
counselor for “stress.” When evaluating the patient, the diagnostic interview content should
include psychosocial questions that address
(A) depression and suicidal ideation
(B) substance use
(C) risk of domestic violence
(D) all of the above
(E) none of the above, while the patient
should grant permission to the pain
physician to speak with her counselor

870. (D) The involvement of a mental-health specialist
in the patient’s care does not absolve the
pain clinician of covering standard psychosocial
interview questions within the assessment
interview. State regulations also may require
that the clinician address risk factors associated
with domestic violence, and the above
case would appear to suggest the presence of
this risk. The pain clinician also must be aware
or have access to resources for appropriate
referral in cases where patients may be at risk.


871. Patients with cognitive impairments and pain
(A) may require administration of specific
assessment tools relevant for their
impairment, as standard pain assessment
may be inadequate
(B) may be at risk for undertreatment of
pain because of communication difficulties
with the pain clinician
(C) are at higher risk for accidental injury
(D) do not necessarily have an intellectual
(E) all of the above

871. (E) There are a range of conditions that require
special attention by the pain clinician, for example,
patients with dementia, head injuries,
stroke, memory disorders, or developmental
disabilities. These disorders can influence the
patient’s social and psychologic presentation,
and their ability to communicate level of pain
and impairment. Comanagement of similar
patients with subspecialists in neurology,
neuropsychology, occupational therapy, and
related disciplines may maximize positive


872. Adjunctive psychologic treatments for cancer
pain might include
(A) cognitive therapies to improve patient’s
control over the medical treatment
(B) autogenic relaxation training
(C) hypnosis
(D) brief family therapy
(E) all of the above

872. (E) While acute and cancer pain conditions may
require a modification of techniques, behaviormanagement
strategies are often integrated into
multidisciplinary treatment team management.