Structured clinical interview

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A structured clinical interview is typically performed as part of any comprehensive psychological evaluation and

Table 10.1 Contents of a pain questionnaire.

Category

Detail

Demographic characteristics Pain characteristics

Circumstances of onset of pain Review of previous medical history Social environment Functional status

Age, marital status, ethnicity, occupation, and educational level

Location, intensity (typically evaluated on a 0-10 rating scale regarding least, average, and worst severity), duration, sensory and affective descriptors, what makes the pain better and worse, and interference with sleep Date, traumatic onset versus insidious onset

Previous pain interventions and their efficacy, prior hospitalizations for pain, current and past medication use, litigation and compensation status Interference of pain in marriage, sexual ability, and social/recreational activities Current employment status, interference of pain on activity levels, working ability, number of hours spent resting during the day because of the pain, number of blocks able to walk, ability to perform household chores, such as laundry, meal preparation, cleaning, shopping, child care, and financial management assessment of chronic pain patients. It represents a good opportunity to review the data obtained on the pain questionnaire, which often may be incomplete or inconsistent. It is an even better opportunity to observe the patient and his/her subjective experience of pain, as well as any illness behavior (facial expressions, frequent posture change, and guarding/bracing). It is an excellent idea to evaluate the patient together with their significant other and their interactions with each other and the interviewer. This facilitates evaluation of the response of the significant other to the patient's pain - whether it is a solicitous, punishing, or distracting response,12 and can be a valuable educational tool for the patient, significant other, and interviewer.

The clinical interview is ideally suited to review the patient's pain complaints, onset of pain and relationship to trauma, prior medical and psychiatric history, prior alcohol and drug usage. It also reviews current marital and family environment, current functional level, disability status, motivational level to return to work, primary, secondary and tertiary gain issues, ability to sleep, and utilization of coping skills. Coping strategies that lead to less pain are the active ones, such as staying busy and distraction. The bad coping strategies that lead to more pain are the passive ones - restricting activities, dependency, wishful thinking, and catastro-phizing (seeing everything in a negative light). An additional area of investigation of the clinical interview, particularly with women presenting with chronic pelvic pain, is a history of childhood physical, emotional, or sexual abuse. Studies have shown a high rate of incidence of childhood abuse appearing later in adulthood as physical pain.

Patients with chronic pain often have a traumatic onset etiology. A significant number of patients seen by chronic pain specialists may therefore experience considerable amounts of psychological distress and some may have posttraumatic stress disorder (PTSD). PTSD has been estimated to occur in about 10 percent of chronic pain patients. When patients with pain as a result of an accident are referred for psychological treatment, the reported PTSD rates increases from 50 to 100 percent. The failure to diagnose and treat PTSD properly in chronic pain patients can lead to minimal or inadequate pain relief. A useful assessment measure for patients with chronic pain and trauma is the Posttraumatic Chronic Pain Test (PCPT).13 The PCPT contains six true-false items that evaluate the presence of PTSD related to the accident that caused the patient's pain.

The clinical interview also affords the opportunity to evaluate the patient's beliefs and cognitions about their pain. However, the primary utility of the clinical interview is to formulate a diagnosis in conjunction with the standardized questionnaires. Particular diagnostic categories carefully evaluated for include levels of depression and anxiety, PTSD, and somatization disorders. This facilitates the design of a comprehensive treatment plan, devised together with the patient as well as the rest of the multidisciplinary team.

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