Sample Report: Pain Management Initial Evaluation
Presenting Characteristics: The patient is a 57-year-old married Caucasian female. She presented herself for interview dressed and groomed appropriately and casually. Interpersonal presentation was friendly but somewhat reserved. Eye contact was normal and sustained. Speech and voice quality were unremarkable. The patient appeared obese. Posture was good. Her affect appeared slightly dysphoric.
Presenting Issues: The patient presents for consultation regarding ongoing back pain. The patient did not appear to be a good historian, generally giving very vague and general answers, even when questioned on specific matters. However, the patient did report that she first injured her back when she was in the sixth grade. She reports that she was always active in school but that her back generally hurt and got worse over the ensuing years. The location of her pain is described as in her lower back, also her left leg and occasionally up in her left shoulder and neck area. She describes the pain as burning. The patient indicates that her pain interferes a great deal with her ongoing activities. However, she generally maintains her household and does all the attendant chores. However, she does not appear to be very active or engaged in any other activities outside the home.
Psychological Symptom Pattern: The patient indicates that she felt somewhat suicidal in the past. When questioned about this, she indicated that she had no active plan for suicide but that sometimes wishes she would die. The patient indicated that she was sometimes quite disgusted with herself because she cannot do what she used to do. When asked to give an example of this, the patient indicated that she cannot sweep or vacuum anymore and that her husband must take on these chores. She indicated that she still does her usual household chores during the day, but gets frustrated with herself and disgusted because she cannot seem to get her chores done many times.
The patient reports that her sleep is not good. She wakes up frequently during the night. She is not sure what to attribute this to, raising the possibility that it could be attributable to a patient-identified ongoing heart problem, to her need to urinate frequently, to her coughing spells from a recent bout of pneumonia, or to her pain. She notes that her sleep is worse since September, primarily, in her mind, due to the onset of the pneumonia.
The patient reports that her appetite is off a bit and that she has lost 20 pounds over the past several months. The patient further reports that she feels tired and rundown every day since her pain has increased over the past few months. She notes that she feels like she cannot change anything and appears somewhat resigned to her life continuing as it has.
The patient reports some reduction in her usual activity level, which she attributes to the pain. There appear to be very few, if any, reinforcing activities in this patient's behavioral repertoire. The patient does not appear to have neglected her personal appearance and denies ongoing crying spells.
Interpersonally, the patient interacts somewhat with her family and children, although she does not appear to be a very socially engaged peson. There appears to be no loss of significant relationships, lack of necessary social skills, or change in life status recently.
Cognitively, the patient reports a low general sense of self-worth and appears to exhibit a great deal of self-criticism and reproach.
Social/Interpersonal History: The patient lives with her husband of 38 years. The patient and her husband have produced six children of this marriage and 11 grandchildren. They are currently living with one of their grandchildren, a 16-year-old granddaughter. When questioned about this, the patient reported that this granddaughter's mother had remarried an alcoholic man and could not handle her being at home at this time. The granddaughter has been living with them for one year. The patient's husband has retired and is reported to be suffering from cardiomyopathy. She denies any ongoing marital problems between the two of them.
The patient denies use of alcohol or tobacco. Reinforcing activities include reading or watching TV.
Medical Background: Details of the medical background may be found in the physician's report. The patient reported to this interviewer that in addition to the back pain she also has a history of Bell palsy and whiplash. She reported that the whiplash was suffered approximately 27 years ago. She was treated with a cervical collar and at-home traction. The patient reports that the Bell palsy consists of spasms in her face and neck. She notes that if she is able to relax, the spasms will be prevented or will subside. The patient also reports a history of rheumatoid arthritis. The patient had back surgery approximately three years ago. She reported that the pain decreased for several days following the surgery but then increased to its original level.
The patient reports no previous or ongoing psychotherapy.
Results of Psychometric Examination: As part of the overall evaluation, the patient took an MMPI, a Beck Depression Inventory, and a Multidimensional Pain Inventory.
The results of the MMPI are invalid. The patient's profile is similar to others who have a strong tendency to exaggerate their symptomatology in an effort to look worse than they actually are on the examination. Thus, the patient's MMPI cannot be interpreted.
The patient was classified in the interpersonally distressed category on the Multidimensional Pain Inventory. Persons with scores in this range generally have higher than average levels of received punishing responses from a significant other, lower than average levels of perceived solicitous responses, and lower than average levels of perceived distracting responses from a significant other. The patient reports a high degree of pain severity and a high degree of interference in her life from the pain. The patient's general activity score is below the average when compared with other pain patients. Persons with scores in the interpersonally distressed area generally indicate that they are not being supported in an appropriate way by significant others, that they are not being taken care of, and that, in fact, significant others may punish them when they exhibit pain behaviors.
The patient obtained a total score of 22 on the BDI. Scores in this range are indicative of persons with a moderate to high level of clinical depression.
Diagnostic Hypothesis: AXIS I: 311.00, depressive disorder, not otherwise specified.
Summary and Recommendations: The patient was moderately verbal throughout the course of the interview; however, she gave few details and exhibited little insight into her pain or psychological or psychosocial issues. It does appear from the psychometric testing that the patient is depressed when compared with others and also exhibits a great deal of self-criticism and reproach. The patient also appears to largely lack any reinforcing activities in her life, and the results of the MPI would indicate that her relationship with her significant other, as far as her pain coping, needs further attention. The results of the MMPI are invalid, but they would indicate somebody who may be exaggerating her symptoms as a possible cry for help.
Based on these results, the following recommendations are made
1. That this patient be seen at least on several more occasions in order to assess her motivation to engage in a behavioral self-management program. If the patient is not so motivated, basic motivational interviewing strategies should be undertaken in an effort to increase the patient's motivation.
2. That this patient's husband should be included in at least some of these sessions to ascertain his reactions to his spouse's pain and to encourage their involvement in more reinforcing activities and more positive communication.
3. That this patient be given some basic strategies for managing her moods. This information would be primarily from a cognitive behavioral perspective.
4. To coordinate this patient's care with pain center medical personnel in an effort to increase this patient's activity level and general functioning.