Influence Of Psychosocial Factors On Chronic Pain

By Sandra Monteiro
Atherton Barristers

For some time now, chronic pain has been a recurring problem that is not only difficult to understand and manage, but also accounts for a significant percentage of all general damages awarded. It is a frustrating predicament for everyone concerned – the patient, their family and friends, employers, physicians, and insurance companies.

In the article Psychosocial Factors Provide Clues to Pain from the American Psychological Association, psychosocial factors are said to be potent enough to enable researchers to predict who may develop chronic pain. According to psychologist Robert Gatchel of the University of Texas, the longer pain lasts without relief, the more difficult and expensive it becomes to treat.

In the case of low back pain, only %5-10 of people with acute pain develop chronic pain, which is defined in this article as lasting more than six months. More recent research, however, indicates that it is now defined as lasting more than three months. Nevertheless, according to this article, chronic pain disability appears to account for %80 of the money spent for back care in the United States.

Research Findings

In a study involving 504 people with acute low back pain, Gatchel and his colleagues identified four psychosocial factors that enabled them to predict whose pain became chronic. Those who still remained disabled by their pain a year after it began:

• Reported more intense pain and more disability from their pain;
• Scored higher on a scale 3 Minnesota Multiphasic Personality Inventory (a measures of a person’s sensitivity to bodily sensations, as well as a tendency to deny any emotional or interpersonal difficulties);
• Received some type of worker’s compensation or were involved in a personal-injury case; and
• Were more likely to be women.

These factors interact to predict pain. Therefore, it does not follow that more women than men develop chronic back pain. It just means that of those scoring high on the other three factors, women more often than men will develop chronic pain. Gatchel believes many of these factors relate to motivational issues. People receiving compensation have little motivation to return to work if they still feel pain. Remaining sedentary, however, only increases the likelihood that pain will linger. He concludes that if clinicians can get these patients back to their normal routine as soon as possible, it may help prevent motivational issues from developing in the first place.

In the same article, Dennis Turk, of the University of Washington, claims that a psychosocial assessment is critical to getting people the treatment they need. He argues that anyone with chronic pain should be assessed medically and psychosocially even before being treated. Turk and his colleagues have defined three sub-types of patients encountered at pain centres:

1. Dysfunctional patients;
2. Interpersonally distressed patients;
3. Adaptive copers.

He concludes that the key to successful treatment is to tailor the treatment to match a person’s psychosocial diagnosis.

In a more recent article found in the BC Medical Journal, entitled Diagnostic Judgment: Chronic Pain Syndrome, Pain Disorder and Malingering, authored by two psychologists and a professor of orthopedics, it is noted that some patients demonstrate illness behaviour due to environmental circumstances.

According to these authors, it is important for physicians to distinguish pain from physical impairment and differentiate illness behaviour from disability. While delayed recovery may be the result of failure to detect physical pathology or psychiatric disorders, a subgroup of patients demonstrate illness behaviour in the absence of detectable underlying physical or psychiatric impairment. Environmental contingencies are responsible for the illness behaviour seen in these patients.

This can be explained by viewing pain as a learned behaviour. Specifically, direct reinforcement of pain behaviours may occur if these are followed by positive consequences. Indirect reinforcement may also occur when pain behaviour leads to the avoidance of or reduction of unpleasant events. So, for example, pain symptoms may become more intense, more frequent and more disabling when followed with (a.) attention from others, (b.) the pleasurable effects of prescribed drugs, (c.) monetary gains of litigation or disability compensation, and (d.) the avoidance of distasteful activities.

Of interest, these authors state that in a longitudinal study of the recovery of 117 people from an acute back pain episode, patients involved in litigation showed the presence of chronic pain reactions within 8 days of the onset of pain. Those already in contact with their lawyers or planning litigation reported significantly more daily disruption in household chores and had significantly higher reports of pain impact compared to reports of pain of those not engaged in litigation.

Further, according to these authors, epidemiological studies have revealed that the following psycho-socioeconomic factors place an individual at high risk for reporting delayed recovery subsequent to trauma:

• Previous history of compensable injuries and occupational disability
• History of psychiatric problems
• Substance abuse
• Recent psychosocial stressors
• Access to disability benefits
• Unresolved litigation
• Job dissatisfaction
• History of poor work performance

Life and work difficulties also predicted whether employees would subsequently be off work because of back pain, as did the Minnesota Multiphasic Personality Inventory-2 scale three scores and the level of enjoyment of work tasks.

Conclusion

In conclusion, these authors argue there is a need to encourage rehabilitation, not disability. Clinicians must avoid confusing their role as advocates for their patients with their responsibility for objectivity. It is recommended that perhaps an independent physician is the one who can rate impairment most objectively, accurately, and unemotionally. In many cases of delayed recovery, interdisciplinary assessment may also be warranted. In all cases the authors believe early intervention is essential.

These recommendations certainly appear to support the insurer’s position that Independent Examinations are more objective and also serve to refute the old argument from plaintiff counsel that an Independent Examiner is a “hired gun”. Further, the articles support the suggestion that an Independent Examination may be a more appropriate method of determining what is in the claimant’s best interests from a rehabilitative perspective given that the claimant’s own physicians may be unknowingly reinforcing their disability.

It therefore becomes apparent that when faced with a claimant who suffers from chronic pain it is not an easy task for all parties involved. The challenge becomes how best to approach and tackle the situation, keeping in mind that the goal is always to return the claimant as close as possible to his or her pre-accident level of functioning. This challenge, of course, comes as no surprise to the adjuster who is faced with such a claim.

The research suggests that there are many psychosocial factors at work that not only appear to be impediments to rehabilitation, but also may cause the onset of chronic pain. The aim therefore should be to avoid, or at least to minimize, the influence of psychosocial factors that tend to reinforce pain behaviours. This, of course, requires the efforts of all parties – the patient, family and friends, employers, physicians, etc.

From the insurance adjuster’s perspective, it proves more difficult to make a difference. This, however, does not mean that nothing can be done. As can be seen from the above research, there are some factors that appear to predict who may be at risk of developing chronic pain. Keeping these in mind while reviewing medical and other information received may be enough to alert the adjuster handling the claim that there is a risk of chronic pain development, or at the very least, detect its onset at an early stage. It may prove useful for the adjuster to ask the following questions when interviewing a claimant at the initial stages:

• Does the cliamant have a history of receiving worker’s compensation benefits or being involved in a personal injury case?
• Is the claimant female?
• Is there a history of psychiatric problems?
• Is there a history of substance abuse?
• Are there any recent psychosocial stressors?
• Does the claimant have access to disability benefits?
• Is the claimant involved in unresolved litigation?
• Does the claimant exhibit serious job dissatisfaction?
• Does the claimant have a history of poor work performance?

Although not an exhaustive list, asking these questions may help the adjuster to assess early on who may be at risk of developing chronic pain. If such a risk exists, the adjuster may then wish to consider having an Independent Assessment done in order to determine which treatment would best match the needs of the claimant. Tailored treatment intervention at an early stage may be enough to minimize the impact of any existing psychosocial factors that may be reinforcing chronic pain, and in turn, have the desired effect of rehabilitating the claimant to a functional level where a return to some form of work is possible.

Outside of those cases where a real risk of chronic pain development exists, the above research may also prove useful in lending further support to an insurer’s position when faced with a claim where there is a well founded suspicion the claimant may be malingering.

For more information on how we can assist you, please contact us at Atherton Barristers at 416-365-1030 or toll free at 866-237-1030.

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