Chapter 11. Behavioral and Psychological Aspects of Pain Flashcards Preview

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1
Q
  1. Primary affective symptoms that are present
    with chronic pain
    (A) generally resolve when the pain is treated
    adequately
    (B) require treatment independent of the
    pain
    (C) are rare among the elderly
    (D) are always reactive or secondary to the
    pain
    (E) require thorough assessment by a psychopharmacologist
A
  1. (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.
2
Q
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
A
  1. (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
    completion.
3
Q
  1. Tricyclic antidepressants
    (A) have been shown to assist with reducing
    neuropathic pain
    (B) have been shown to assist with chronic
    headache
    (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
A
  1. (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.
4
Q
  1. 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
A
  1. (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
    treatment.
5
Q
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
A
  1. (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.
6
Q
  1. Spouse “oversolicitous” behavior
    (A) can be assessed with the Minnesota
    Multiphasic Personality Inventory-2
    (MMPI-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
A
  1. (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.
7
Q
  1. 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
A
  1. (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
    providers.
8
Q
  1. 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
    present
    (D) anxiety symptoms rarely abate after
    adequate treatment of pain
    (E) both B and C
A
  1. (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.
9
Q
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
setting
(C) the patient’s level of depression
(D) the adequacy of the patient’s pharmacotherapy
regimen
(E) all of the above
A
  1. (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.
10
Q
  1. 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
A
  1. (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.
11
Q
843. Biofeedback assisted relaxation has been
shown to be effective in reducing frequency,
duration, and severity of pain with
(A) myofascial pain conditions and
migraine
(B) cluster headache
(C) trigeminal neuralgia
(D) postherpetic neuralgia
(E) all of the above
A
  1. (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.
12
Q
844. In general, compliance rates or “adherence”
with pharmacotherapy recommendations is
(A) 70% if a chronic medical condition is
present
(B) dependent upon the severity of the
chronic condition
(C) greater with elderly patients
(D) dependent on the patient’s intelligence
level
(E) improved when the pain clinician is
“emphatic,” and readily accepts the
patient’s report of pain severity
A
  1. (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.
13
Q
  1. 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
A
  1. (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.
14
Q
  1. 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
    disorder
    (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
A
  1. (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.
15
Q
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
A
  1. (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….”
16
Q
848. Commonly used quality of life measures
include
(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
A
  1. (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.
17
Q
  1. 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
    implantation
    (D) address possible malingering by the use
    of standardized psychologic testing
    (E) all of the above
A
  1. (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.
18
Q
  1. 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.
A
  1. (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.
19
Q
  1. 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
A
  1. (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.
20
Q
  1. 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
A
  1. (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.
21
Q
  1. Pain support groups and online support organizations
    (A) may reinforce the patient’s somatic
    overconcern and promote disability
    behavior
    (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
    provider
    (D) are not a replacement for psychologic or
    psychiatric treatments
    (E) all of the above
A
  1. (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.
22
Q
  1. 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
A
  1. (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.
23
Q
  1. The Minnesota Multiphasic Personality Inventory
    (MMPI-2)
    (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
    choice
    (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
A
  1. (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.
24
Q
  1. 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
    psychotherapy
    (C) Contingency management, stimulus
    generalization, and operant conditioning
    (D) Surface electromyographic (EMG)
    biofeedback, thermal biofeedback, and
    muscle reeducation
    (E) All of the above
A
  1. (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.
25
Q
  1. 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
A
  1. (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
26
Q
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
A
  1. (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.
27
Q
  1. 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
    therapy
    (B) Return to work and increase in recreational
    activity
    (C) Reduced pain and depression
    (D) Improved aerobic capacity and reduced
    side effects from opioids
    (E) None of the above
A
  1. (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
    techniques.
28
Q
  1. “Mind-body” and structured “stressmanagement”
    programs often employ
    (A) short-term, time-limited treatment
    techniques
    (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
A
  1. (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.
29
Q
  1. Cognitive behavioral treatments with pain in
    children might typically include all of the following
    EXCEPT
    (A) enlisting parents to assess mediating
    stressors and reinforce positive coping
    skills
    (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
A
  1. (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.
30
Q
  1. 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
    disorder?
    (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
A
  1. (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.
31
Q
  1. 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
    techniques
    (D) low-dose chronic opioid therapy and
    thermal biofeedback
    (E) none of the above
A
  1. (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.
32
Q
  1. 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
A

.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.

33
Q
  1. 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
    treatments
    (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
    treatment
    (E) should never be treated with chronic
    opioid therapy
A
  1. (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
    specialists.
34
Q
  1. 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
    migraine
    (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
A
  1. (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
    interventions.
35
Q
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
A
  1. (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.
36
Q
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
A
  1. (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.
37
Q
  1. There is empirical evidence to support
    (A) the construct of a “pain prone personality”
    (B) the concept that chronic pain is “masked
    depression”
    (C) malingering as being rare, less than 1%
    with work injury-related chronic pain
    conditions
    (D) the assumption that psychologic trauma
    may increase the likelihood of developing
    a treatment-resistant chronic pain
    disorder
    (E) all of the above
A
  1. (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.
38
Q
  1. 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
A
  1. (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.
39
Q
  1. 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
    disability
    (E) all of the above
A
  1. (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
    outcome.
40
Q
872. Adjunctive psychologic treatments for cancer
pain might include
(A) cognitive therapies to improve patient’s
control over the medical treatment
sequence
(B) autogenic relaxation training
(C) hypnosis
(D) brief family therapy
(E) all of the above
A
  1. (E) While acute and cancer pain conditions may
    require a modification of techniques, behaviormanagement
    strategies are often integrated into
    multidisciplinary treatment team management.