Appendix C
Psychological Screening and Pain
Management Skills
Depression Screening
Hilton and colleagues developed and validated a ten-item screening tool for depression in medically ill patients, called the Depression in Medically Ill screen or DMI10.1 An adaptation of this self-report questionnaire is presented below:
Name:_______________________________________; Date:_____/_____/_____
Please rate each statement, considering how you have been feeling in the last 2 to
3 days compared with how you normally feel:
Not true
Slightly true
Moderately
true
Very true
Score = 0
Score = 1
Score = 2
Score = 3
I find myself stewing over things
I feel more vulnerable than usual
I am critical of or hard on myself
I feel guilty
Nothing seems to cheer me up
I feel like I have lost my core or
essence
I feel depressed
I feel less worthwhile
I feel hopeless or helpless
I feel distant from other people
Scoring: Sum scores from each question. A total score ≥ 9 suggests depression
1
Parker G, Hilton T, Bains J, Hadzi-Pavlovic D. Cognitive-based measures screening for depression
in the medically ill: the DMI-10 and the DMI-18. Acta Psychiatr Scand 2002;105:419–426.
D. Marcus, Chronic Pain: A Primary Care Guide to Practical Management,
© Humana Press, a part of Springer Science + Business Media, LLC 2009
401
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Appendix C Psychological Screening and Pain Management Skills
Anxiety Screening
Spitzer et al. developed and validated a seven-item screening tool for anxiety in
primary care patients, called the General Anxiety Disorder-7 (GAD-7).2 An adaptation of this self-report questionnaire is presented below:
Name:_______________________________________; Date:_____/_____/_____
Choose one description for each item that best describes how many days have you
been bothered by each of the following over the past 2 weeks:
None
Several
7 or more
Nearly every day
Score = 0
Score = 1
Score = 2
Score = 3
Feeling nervous, anxious, or on
edge
Unable to stop worrying
Worrying too much about different
things
Problems relaxing
Feeling restless or unable to sit
still
Feeling irritable or easily annoyed
Being afraid that something awful
might happen
Scoring: Sum scores from each question. A total score of 5–9 suggests mild anxiety, while a score
≥10 suggests moderate to severe anxiety
2
Spitzer RL, Kroenke K, Williams JW, Löwe B. A brief measure for assessing generalized anxiety
disorder. The GAD-7. Arch Intern Med 2006;166:1092–1097.
Psychological Pain Management Techniques
403
Psychological Pain Management Techniques
Many effective pain management techniques are taught by psychologists. These
techniques are designed to help reduce muscle spasm and the number of pain
messages sent by the brain. These techniques are effective for most people with
chronic pain. Pain improvement after using these techniques does not mean that
the pain was imaginary or psychological. Additionally, these techniques are not
designed to treat serious psychological problems, such as depression and anxiety. Relaxation training, biofeedback, and stress management are among the
many techniques taught by psychologists. Patients achieve the most benefit
from these techniques when they receive some formal training from an
experienced therapist.
Relaxation
Relaxation techniques should be learned while sitting in a comfortable chair, with
arms and legs uncrossed, feet flat on the floor, and eyes closed. Each practice session should last for about 15 to 20 uninterrupted minutes. Once you have regularly
practiced and mastered these techniques, you will be able to use them whenever
you feel yourself starting to tense or in anticipation of stress.
●
●
Progressive muscle relaxation involves alternately contracting and relaxing
muscles throughout your body. With your eyes closed, tense and then relax
individual muscles in different parts of your body, starting at your feet and
moving toward your neck and face. Hold the tension for 10 to 15 seconds, then
release. Tense and release the muscles in your feet, then in other parts of the
body in the following order: legs, abdomen, arms, shoulders, neck, jaw, eyes,
and forehead. Focus on the sensations of the muscles when they are no longer
tensed. With practice, you will begin to recognize when your muscles are
tensed. For example, you may notice tension in your face, neck, and shoulders
when sitting in traffic or waiting in a line at the store. Once you feel this tension, work to release it before your pain flares.
Cue-controlled relaxation uses a combination of deep breathing and repetition of the word relax. Begin this exercise with a slow, deep, abdominal
breath. Place your hand over your abdomen to feel it moving in and out with
each breath. After inhaling, hold the breath for 5 to 10 seconds, then exhale,
slowly repeating the word relax. Repeat. After you are comfortable with this
technique, you should be able to close your eyes and take a deep abdominal
breath before confronting stressful situations, e.g., a doctor’s visit, a meeting
with the boss, or a discussion with your teenager. This will reduce the impact
of stress on your pain.
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Appendix C Psychological Screening and Pain Management Skills
Thermal Biofeedback
●
●
Some people find it difficult to feel relaxed and use biofeedback as part of their
relaxation training as an external monitor. To begin, place a handheld thermometer on your finger and measure the temperature. While practicing relaxation
skills, check the temperature on your thermometer. When you are relaxed, the
finger temperature should increase by about 2 to 3°F (probably to about 96°F).
An inexpensive finger thermometer and biofeedback audiotape may be obtained
from Primary Care Network (1-800-769-7565).
Stress Management
Stress is one of the most common triggers for pain flares, aggravating pain in about
30% of people with chronic pain. Individuals usually notice that stress aggravates
their usual health problems: people with heart disease experience chest pain; people
with irritable bowel syndrome develop diarrhea, and patients with chronic pain
have pain flares. Stress management does not mean avoiding or eliminating all of the
stress in your life. Instead, you train your body to react differently when exposed
to stress so that your pain is less likely to become flared. For example, many people
feel stressed when stuck in traffic, reacting with anger, clenched teeth, and tightening of muscles in the neck and upper back. After learning stress management, you
may still get stuck in traffic, but you will be able to respond by repeating soothing
thoughts (“I will make my appointment. I am a responsible person.”) or listening to
music while practicing relaxation techniques (such as slow, deep breathing). In this
way, your body will not release pain-provoking chemicals or cause muscle spasm,
both of which may aggravate your pain condition. These same strategies can be
used before attending a meeting with one’s boss or a child’s teacher, before beginning a discussion about family issues with spouse or child, or while waiting in a
long line at the grocery store.
Most people experience stress symptoms when exposed to new environments
and situations. Identify situations that are typically stress provoking for you, that
cause you to feel your jaw or hands clench or begin to sweat. For some people,
major events – such as taking an examination in school or giving a speech or a business presentation – will result in a stress response. For others, seemingly minor
events – such as making a phone call, driving in traffic, meeting a child’s teacher,
or even meeting an old friend – may be stress provoking. Understanding your
body’s reaction to frequent situations allows you to plan to use relaxation techniques and stress management immediately before each event to minimize the
stress response and the impact stress will have on your chronic pain.