In my last post I started to discuss the questionnaire domains that can be used in a battery of questionnaires for chronic pain. Today it’s time to turn to the specific measures that we’ve chosen as part of a set that a group working across the public health system in New Zealand have selected. It’s hoped that eventually the responses from these questionnaires will be as available within the national DHB patient information system as the results from radiology and lab tests. Imagine that!
Below are the domains as I indicated yesterday.
Mood and anxiety – depression, anxiety and pain-specific anxiety were chosen because of their importance to outcomes, and the need to treat psychopathology
Catastrophising – because this is thought to be one of the most important aspects of cognition that needs to be addressed
Pain-related anxiety and avoidance – because this appears to be one of the strongest predictors of ongoing disability
Acceptance – this domain has been emerging as an increasingly important treatment process variable, and may be a target for intervention
Pain location and intensity – yes, we do ask, just in case you wondered!
Pain self efficacy – again, this seems to be an important process variable, and a target for treatment. It’s also associated with higher levels of disability.
Pain-related disability – this is, hopefully, one of our most important outcomes, so we measure this more than once.
Please note: these are not the only areas assessed, these are the areas that are assessed using questionnaires.
BEFORE YOU USE A QUESTIONNAIRE: the normative data may not be relevant to the people you’re seeing – always establish the population it is based on. With any questionnaire: please read the original article, understand how it was developed, and be familiar with the interpretation before you use it. NEVER rely on just a questionnaire for diagnosis, you must conduct a clinical interview as well. Questionnaire results provide a guide for further enquiry and are useful as an outcome measure.
Mood: There are, as we all know, many many many questionnaires available for mood. We wanted a relatively brief measure (who doesn’t!), and one that had been used in a clinical population and also within a general healthcare setting rather than specifically a mental health setting.
While some of us would have preferred a ‘pure’ measure of depression, we ended up choosing the DASS-21. (Here’s a brief description of it) Depression Anxiety Stress Scale is the full title, it was developed by Lovibond and Lovibond (reference below), and you can obtain pdf copies of both the questionnaire and interpretation here (go down the list until you find the instructions).
We had been using the CESD, and liked the factor structure of it and, as I said, the pure mood measure; but to help maintain consistency across the country, we agreed to use the DASS which is widely used in general health settings (as opposed to mental health settings).
Anxiety: The DASS includes both depression and anxiety, and we recognised that anxiety is an important domain to include for people with chronic pain. We reviewed a number of papers and identified that the Pain Anxiety Symptoms Scale measures pain-related anxiety in a way that is particularly helpful for generating treatment options. The PASS-20 has been found to have a four-factor structure (Physiological arousal, Fearful appraisal, Cognitive anxiety, Avoidance). Although some people thought that having a separate measure of pain-related anxiety was unnecessary, our reasoning is that because this is a specific measure to pain, it will provide us with more fine-grained analysis of some of the processes underpinning distress and disability. We are lucky enough to have New Zealand (Burwood chronic pain patients) normative data for the PASS, so we think this is a useful measure to include.
Catastrophising: There is little doubt that catastrophising as a construct is important in the generation and maintenance of disability and distress in chronic pain. After reviewing the range of assessment instruments, the best contender is the Pain Catastrophising Scale. (here’s a great review of catastrophising – and it’s open access!) No arguments there! It’s quite short, it’s used widely both in research and clinical practice, and there is plenty of literature available to support interpretation.
I’ll post on the remaining assessments shortly, and also discuss some of the really practical aspects that we’ve looked at in the process of generating this battery of tests. I hope this is helpful!
Sullivan, M., Bishop, S., Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation.
Psychological Assessment, 7(4), 524-532. DOI: 10.1037/1040-35126.96.36.1994
Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995; 33: 335–342.
McCracken LM, & Dhingra L (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain research & management : the journal of the Canadian Pain Society = journal de la societe canadienne pour le traitement de la douleur, 7 (1), 45-50 PMID: 16231066