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.
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.1 Adherents to the biopsychosocial, mind-body, and behavioral medicine approaches to pain all affirm that, while the origin of pain may not be psychological, how a person 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.
The principal goal of psychosocial assessment in chronic pain is not, as some patients fear, to determine whether or how much pain can be attributed to psychological sources but rather to identify the emotional, behavioral, and social factors that may be rendering it less tractable to treatment and moving the patient toward physical and psychological disability. The development of a successful plan for treatment often depends on identifying these influences and strategizing how to address them expediently, sensitively, and thoroughly.
It is helpful, early in the assessment process, to have access to the patient's previous medical records. The records can help in understanding the nature and severity of the underlying medical condition, the suspected peripheral pain generators, the response to previous medical treatments and the rationale for those that are planned, and the expected natural history of the disorder. This background, as it is understood and misunderstood by the patient, becomes highly influential in framing the challenges of treatment. Knowing the biomedical context can be a helpful bridge for conceptualizing and explaining, both to the patient and to other members of the treatment team, what role psychological factors may play. Discrepancies between the medical record and how a patient ...