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Why does one patient develop chronic pain and face disability,
while another—with seemingly the same injuries, extent
of tissue damage, and quality of medical care—recovers
and returns to normal activity following a brief convalescence?
Arguably, there may be biologic variables between the two that are
difficult to discern medically, but a comparison, in most cases,
is likely to reveal that the greater portion of the variance consists
of psychosocial differences. When pain physicians wonder why a patient
fails to respond to procedures and medications that have proven efficacious
for many others with the same medical presentation, it is frequently
the pain psychologist who can offer the most reasonable and, more
importantly, functional set of hypotheses.
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Although nociceptive or purely physiologic factors may instigate
pain, how it is expressed by the individual, over time, suggests
that what might have begun as a simple picture can become considerably
more complicated and intricate through the influence of psychological
and social factors. Melzack and Wall’s gate control theory
emphasizes that pain cannot be fully understood without an assessment
of the motivational-affective, sensory-discriminative, and cognitive-evaluative
processes of the individual. Adherents to the biopsychosocial, mind-body,
and behavioral medicine approaches to pain all affirm that, whereas
the origin of pain may not be psychological, how one responds to
it is. Assessing this response expediently and accurately may redirect
the focus of a patient’s treatment, highlighting the psychosocial
dimension of the patient’s experience as essential to diagnosis
and successful outcome. Chronic pain may not lead to adjustment
difficulties, mental disorder, and disability, but when it does,
psychosocial assessment may offer the only helpful perspective on
why, as well as the best hope for recovery.
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Social policy and, in some instances, medical practice have lagged
behind science in operationalizing the comprehensive approach to
pain management. Psychological services, for example, are a requirement
for pain treatment centers seeking accreditation by the Commission
on Accreditation of Rehabilitation Facilities (CARF)1;
yet many health insurance carriers balk at the idea of reimbursing
for psychological evaluation and treatment, and there are no uniformly
endorsed standards in the private sector. In medical practice, physicians
who do not see their patients in a multidisciplinary setting may
not involve psychological evaluation in cases of chronic pain, until
considerable frustration and the question of functional versus organic
origin has arisen. Ironically, by that time, the interpretation
of the patient’s pain has often passed from a medical to
a wholly psychological one, and the wish not to affront or unduly
alarm the patient is well past consideration.
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When patients are asked to see a psychologist or to complete
a battery of psychological tests and questionnaires, many indeed
respond defensively and, sometimes, even hostilely. For many, referral
to a psychologist is tantamount to confrontation with their worst
fear: “My doctor doesn’t believe me.” How
the physician approaches the patient, therefore, frequently becomes
the first crucial step toward putting together a comprehensive picture
of what the ...